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Discussion

Confused with Charting

Hello everyone! I'm newly hired on a SNF and care for about 25 residents for the night shift. I know I have to with those who were unstable during the night, but what about the rest? Do I need to make charting/progress notes on all 25 residents at the end of the shift? If not, whom exactly should I chart? Thank you!

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    • Featured Replies

    On non - skilled residents you usually chart on those who have had recent falls, skin tears, bruises, other injuries, on antibiotics, new meds, med changes, changes in condition, new behaviors, old behaviors, refusal of meds/treatments, exit-seekers, increased assistence needs, etc. You will likely only have a handful of people to chart on on a LTC hall. On a skilled hall, all skilled residents are charted on. This list is by no means all inclusive, but a general guideline to get you started. Hope that helps. :)

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    Follow your facility's policy. Medicare rules...chart every shift for the first 72 hours then daily after that. No need for daily charting on residents who aren't skilled unless something happens.

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    • Expert
    Do I need to make charting/progress notes on all 25 residents at the end of the shift? If not, whom exactly should I chart?
    I wrote all about LTC/SNF charting several months ago. Although some of my colleagues may disagree, it is a very general guideline on occurrences that usually require documentation by the nurse. Click on the link below if you wish to read more.

    https://allnurses.com/geriatric-nurses-ltc/ltc-charting-beginners-899111.html

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    I printed out the headlines in a piece of paper after you posted that and I keep it with me and look at it when I chart so I don't miss anything! It helps when I am playing unit manager and am being my usual scatterbrained self... Thanks so much. :)

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    • Author

    I've obviously missed some of the stuff that I had to chart but nobody seems to notice. It's hard to try to do everything you're supposed to do when no one is pointing out what you're missing out, so I'm grateful for all the help! Thanks everyone!

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