charting

When charting for a fall, look at an experienced nurse's charting at the facility you are working at.

Look for any holes and use that as a template.

LONG TERM CARE...if you can please give me example

how do w do charting in long term care facililites? i am a new nurse, still trying to figure it out? can anyone give me example what to inculde, for PM shift.

It varies by facility and situation; do you chart by exception or do narrative? Ask you facility's clinical educator for specifics. But always document facts only, make sure to hit on reason documenting, like if there is a GI issue, then bowel sounds, last BM, any noted bleeding, continence vs incontinence, and nausea/vomiting/diarrhea. Be factual and succinct, use descriptions as needed. Not much help, but truly, in this age of computer documentation, and preprinted templates or computer templates, it does vary by facility.

I suggest finding out what your facility says to do. We only do narratives on those who are skilled nursing and those where things are going on we need to document. Not sure if this will change when we go electronic.

Write what you see and know. Vitals, general appearance, med changes, appetite, pain level, comments on any wounds etc.

Charting will vary depending on what software, if any, your facility uses. General rule of thumb for incident charting [like falls] is to use an SBAR format.

S=situation. Here you will describe the incident as it occurred or how you discovered the resident if the fall was not witnessed. As in what position were they in, were they wearing proper footwear, was there a wheelchair, walker, bed or any other equipment involved, etc. An unwitnessed fall is by far the more common scenario in LTC.

B=Background. Here you will chart the res pertinent dx. Do they have dementia? Is there a history of falls? Is the resident on any anticoag therapy? If they are it is important to include this as it greatly increases the risk of bruising and/or bleeding.

A=Assessment. Here you will chart the immediate post fall assessment. Any injuries found, baseline neuro checks, ROM, etc.

R=Response. Here you will chart what you did. After assessing the resident if there are no injuries was the resident transferred back to bed, chair or standing and how did you transfer them? If there are injuries did you contact either 911 or the MD and transfer the resident to the ER? How did you get them there? Injuries or not this is also where you chart that the MD was notified of the fall [per your facility policies] and that the POA if there is one was notified. If your facility policy requires a round of neuro checks [and it should] this is where you indicate neuro's started per policy.

This is just a basic template used where I work. Our software has the SBAR template included right in the progress note section. Make sure to read up on previous fall/incident charting for your facility to see how it is done where you work and ask your more experienced co-workers for guidance the first few times you need to incident chart.

Even if your facility uses paper charting an SBAR format is easy to remember and follow, but again you will need to be guided by the preferred charting system of your facility.

Hey! Hopefully you've gotten some help already.

One thing you could try to do (in terms of knowing WHO to chart for) is take your brain sheet, census, patient list... Whatever you use. Highlight in yellow the patients you plan on charting for so when you sit down to chart, it's wayyy less overwhelming.

A general rule, most facilities have a schedule or guide on q shift charting. Start with that.

Highlight anyone else such as...

-Patient on IV therapy

-Patient on abt

-Recent change of condition in the last 72 hours

-S/p fall

-PRN's (I don't chart every PRN in every narrative note, but I get most of them documented.)