Confused on Charting in LTC

JB2007, ASN, RN · Oct 6, 2010

I would look up the policy and procedure for these questions. That is the only thing that will cover you butt when they get mad at something you did or did not do. When asked why you did something you can say I followed the policy and procedure.

Nascar nurse, ASN, RN · Oct 6, 2010

i'm a lvn (in tx) that has worked in acute care for a few years. i've recently went to work at a ltc facility in order to finish up my rn. there are a couple of issues i'm confused about and anytime i try to look them up online i get lost in all the websites. i've been work in ltc for about 8 months now and am still a little puzzled about a few things. any help would be greatly appreciated.
1. skilled residents - legally, how many time per day do they have to be charted on? i don't have any problems with people that are on anti-biotics and such but charting on the skilled ones at night is crazy to me. it's starts getting old after the 45th day of 100.
legally they are required to have daily skilled care which is supported with the documentation, ie: daily charting. we rotate between 7-3 & 3-11's. mi.dnights does not do medicare charting
2. mds 3.0 - we were told our charting needs to change for the mds 3.0. i don't really understand what that mean. we were also told not to chart resp even/unlabored but to chart rhonci, wheezing, rales etc. now as a lvn am i legally able to chart breath sounds? i was under the impression only rn's/dr. could chart that. i've always used adventious breath sounds. they were want more of times to bsc and things like that but also more charting on residents moods and things like that. i work night shift so it's hard to assess somethings. i guess i just need a basic template of things to cover in my charting.
find your mds coordinator for your facility and ask for specific examples of what he/she wants
3. falls - at the facility i work at they want us to actually chart in the chart if someone falls. isn't the incident report itself it's "own chart" i know at the hospital we weren't allowed to do that.
the incident report is considered an internal document and not part of the residents legal record. therefore, all incidents are to be documented in the chart.
3. rn/lvn charting - can someone lead me in the right direction where i may be able to find some information stating the difference in charting between rn and lvn. i know it's not the same in the hospital setting but didn't know how different it is in ltc.

this differs from state to state so its going to be hard for anyone to give you an accurate answer on this topic. you will have to look up your own state regs. in my state, an lpn can not hang blood, which we don't do in ltc anyway. they can do iv meds, including iv push meds

MisMatch, LPN · Oct 7, 2010

As a night shift nurse, I agree charting can get monotonous. I am requires to chart on anyone on medicare, abx, new admits, hospital returns and more.

1: For skilled residents, my typical note would have VS if taken, followed by "resting in bed with eyes closed all night, no c/o (or s/s of) pain, discomfort (resp distress if appropriate)". I would also add any behavior or change (in continence, sleep pattern, condition, ect.). I've charted this so many times I feel like a broken record but have never been called out for this.

2: As a LPN, I do chart rhonchi, rales, wheezes, diminished for lung sounds if I am sure of what I am hearing. We have been inserviced on the new MDS 3.0, but not on any differences in charting. There has been yet another piece of paperwork we must fill in on each resident every shift regarding "pain" as a result of the MDS 3.0. Any more paperwork and I'll have NO TIME for patient care!!

3: Yes, we do chart on falls in addition to the incident report. The incident report is much more detailed. The chart might read something like "found on floor at bedside @ 0100, stated "I slid trying to get up to go to the bathroom", denies hitting head, denies pain, VS..., skin tear on L anterior forearm 2 cm x 0.5 cm, (whoever you notify) notified @ 0115."

As for LVN/RN charting, chart what you do, the RN charts what they do. If I notice a change in condition, I chart what I observed, VS, ect then "reported to RN supervisor". The RN makes the decision to call the doc or 911 and makes the call. The RN then charts what they did, ie: "called Dr. B @ 0200, verbal orders to send to X hospital, left via XYZ ambulance @ 0230, (name of POA) notified @ 0235." Notes are usually much more detailed, but hopefully it gives you an idea of the difference.

Hope this helps!

lyric65 · Oct 7, 2010

this differs from state to state so its going to be hard for anyone to give you an accurate answer on this topic. you will have to look up your own state regs. in my state, an lpn can not hang blood, which we don't do in ltc anyway. they can do iv meds, including iv push meds

the facility i work at is pretty small. we have 42 residents. i work 10 - 6 and have 2 cna's. we don't really have a mds person. we just have the admin, don, & adon so it's really hard to really get straight answers. my shift is expected to chard on all skilled/abt plus they do a 4 day charting on several people each week mon-thur. i wish we did have more specialized people instead of one with multiple titles. so at night the charting gets pretty generic i feel like but i don't really know how detailed i can really get when they are sleeping and i'm not wittnessing any therapys and things like that.

lyric65 · Oct 7, 2010

As a night shift nurse, I agree charting can get monotonous. I am requires to chart on anyone on medicare, abx, new admits, hospital returns and more.
1: For skilled residents, my typical note would have VS if taken, followed by "resting in bed with eyes closed all night, no c/o (or s/s of) pain, discomfort (resp distress if appropriate)". I would also add any behavior or change (in continence, sleep pattern, condition, ect.). I've charted this so many times I feel like a broken record but have never been called out for this.
2: As a LPN, I do chart rhonchi, rales, wheezes, diminished for lung sounds if I am sure of what I am hearing. We have been inserviced on the new MDS 3.0, but not on any differences in charting. There has been yet another piece of paperwork we must fill in on each resident every shift regarding "pain" as a result of the MDS 3.0. Any more paperwork and I'll have NO TIME for patient care!!
3: Yes, we do chart on falls in addition to the incident report. The incident report is much more detailed. The chart might read something like "found on floor at bedside @ 0100, stated "I slid trying to get up to go to the bathroom", denies hitting head, denies pain, VS..., skin tear on L anterior forearm 2 cm x 0.5 cm, (whoever you notify) notified @ 0115."
As for LVN/RN charting, chart what you do, the RN charts what they do. If I notice a change in condition, I chart what I observed, VS, ect then "reported to RN supervisor". The RN makes the decision to call the doc or 911 and makes the call. The RN then charts what they did, ie: "called Dr. B @ 0200, verbal orders to send to X hospital, left via XYZ ambulance @ 0230, (name of POA) notified @ 0235." Notes are usually much more detailed, but hopefully it gives you an idea of the difference.

2.I feel exactly the same about the paper work as well. I've got skilled/abt charting, 4 day charting, plus a rounds sheet, census and a communication sheet for the skilled/abt. I write pretty much the same thing on all the paper work. I hate the repetition. We've now had to start charting 02 sat/HR before HHN tx and then after in the mars for the medicare stuff. Lately we've had a lot of sick ones and I pretty much spend 90% of my shift charting since it's just me. I wish I did have another nurse there at night so I could spend more time with the ones awake or during the morning med pass.

3.I wish I had an RN there at night. But it's just me and 2 CNA's. So I get to make all the calls (and more paperwork).

I appreciate your thoughts

mikeicurn, ASN, RN · Oct 7, 2010

I have been working LTC for a month, and I have some of the same problems with charting. I have to chart Med A, ATB and for 7 days on any new admissions. Also vitals, O2 sats, fluids on G-tube Rt's. I also do a census as well. You are right, on night shift it is harder to chart information about behaviours when the Rt's are usually asleep. I have been charting kind of general stuff like.

Rt A&O x3, feeds self with tray setup, ADL's with assist x 1-2, incontinent of bladder with briefs in place, etc...

That is about the best you I can do in the situation. We started using Point Click Care recently and with the computerized charting it is quite a bit easier, but for the first couple of months we also have to do the paper charting as backup. With the Medicare charting you select their primary diagnosis (let's say respiratory) and there are boxes that ask you to fill in the specific information you need to supply. So for example it will say "Lung sounds (ronchi, absent, diminished, etc...)" so you will get some guidance as to what they are looking for. That helped me a lot. For the midnight census I can just print out a midnight census report and it will list all the Rt's that are not discharged by room number. I just have to confirm it's correct and sign it, so that has become a lot easier. I am in KY and LPN's here can hang blood and push IV meds. There is no RN on duty when I work. I can call one of them if I need to, but I am responsible for call MD's, sending Rt's out, etc... It is a lot of responsibility and can be a little overwhelming to a new grad like me.

Good luck and God bless.

lyric65 · Oct 9, 2010

I have been working LTC for a month, and I have some of the same problems with charting. I have to chart Med A, ATB and for 7 days on any new admissions. Also vitals, O2 sats, fluids on G-tube Rt's. I also do a census as well. You are right, on night shift it is harder to chart information about behaviours when the Rt's are usually asleep. I have been charting kind of general stuff like.
Rt A&O x3, feeds self with tray setup, ADL's with assist x 1-2, incontinent of bladder with briefs in place, etc...
That is about the best you I can do in the situation. We started using Point Click Care recently and with the computerized charting it is quite a bit easier, but for the first couple of months we also have to do the paper charting as backup. With the Medicare charting you select their primary diagnosis (let's say respiratory) and there are boxes that ask you to fill in the specific information you need to supply. So for example it will say "Lung sounds (ronchi, absent, diminished, etc...)" so you will get some guidance as to what they are looking for. That helped me a lot. For the midnight census I can just print out a midnight census report and it will list all the Rt's that are not discharged by room number. I just have to confirm it's correct and sign it, so that has become a lot easier. I am in KY and LPN's here can hang blood and push IV meds. There is no RN on duty when I work. I can call one of them if I need to, but I am responsible for call MD's, sending Rt's out, etc... It is a lot of responsibility and can be a little overwhelming to a new grad like me.
Good luck and God bless.

You sound alot like me. I don't chart any AAO unless they are awake as well as assist/transfers. I wish we did have computerized charting. I do think it would be so much more easier. I guess I feel better knowing that I'm not the only that charts just the basics at night:)

RitaLeighann · Mar 4, 2013

Thanks for sharing your experience here. I have learned many things from all you. I am a new graduated nurse and is working at NH. How to correctly make charting is my problem so far. I take 2nd shift (2pm-10:30pm). Please give me some suggestions and ideas. Thanks!

ybanurse · Mar 5, 2013

Skiilled patients get charted on every shift. falls=incident report and nurses notes, Falls are charted on 3 days unless there is an injury then we chart until the injury is resolved. Antibiotics until course finished and then s/p 3 days for any adverse reactions. Anybody on report gets charted on until they come off

ask what the policies are at your facility , carry a notebook with you until you get them downpacked Soon you'll have a routine

RitaLeighann · Mar 10, 2013

Thanks for explaining and introducing about charting. It is helpful to me. Have a nice weekend!

chernandez1208 · Jul 18, 2018

In the state of Washington can an LPN complete the daily skilled charting for Medicare?