Daily Documentation..how do ensure you get it?

I guess my question is "What is the consequence for nurses failing to document the areas required?"

Seems like absolutely nothing to me. My hands are tied with that tho. I can only present it to my DON of the inadequacy.

"Have you educated the specific people and got them to sign your in services?" YES! Speficially one that was HIRED to do Medicare charting Mon-Fri...

I guess what I really am wondering--- what are you guys expectations on daily nursing documentation on surgical sites, pneumonia,chf, cdiff, staged wounds?maybe I'm expecting to much... Unreasonable. (But I don't believe I am...)

I can only speak to this from the staff nurse perspective, since I *just* got offered an MDS coordinator position today and haven't begun working from that end of things. Our facility has had a hard time getting nurses to chart appropriately, despite cue sheets and fyi/reminders on 24 hour reports frequently. One of our supervisors has been piloting something new - putting in the specific documentation requirements as part of our eTAR (we use Point Click Care software) so it goes in as "assess respiratory status each shift and document", or "Assess and Document per CHF Protocol" or CDiff: Assess and Document Bowel", or if someone is on antibiotic for a URI: "Assess and document vitals and lung sounds r/t URI". It's pretty ridiculous that these tasks need to be put in for each shift, because one would think that nurses would know that these assessments need to be done; however, with rehab and skilled nursing facilities being staffed short and nurses being overwhelmed with work, this is where we're at. The unit that this has been implemented has had a significant increase in appropriate detailed and accurate charting. So - sometimes doing a lot of handholding works