Do all of your LTC charts have face sheets?

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I can't believe this LTC FACILITY!:eek: I can say truthfully that approximately 30% of the charts have no face sheets. Nothing. No, I am not talking about the new admits either. There are residents who have been here a long time and still have no face sheet!!!!! The Lab gets mad at us for not putting the social security numbers on the lab sheets as requested. I would love to put the social security numbers on the lab sheets but I have no face sheet where the social security numbers are listed. So I am curious. Are other facilities also missing their face sheets too? Or are we just special?

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Specializes in Gerontology, Med surg, Home Health.

You're special. Our face sheets are in the charts within 24 hours of admission.

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Specializes in LTC, Hospice, Case Management.

All of our charts have a face sheet...most often within an hour of admission (admission director does this as she does the paperwork with the family).

In past facilities, I have noticed that the face sheets often went missing because the nurse would remove them to make a copy (for dr appts, trip to ER, etc. but then end up sending the original out with the resident or just not getting it put back into the chart.

Do you have a computerized charting? If you do then you should just be able to print a new one from the computer.

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Thanks all. No, we don't have computerized charting here. I have worked in many different facilities and have never ever seen such a lack of face sheets. The nurses here say they don't complain about it anymore. They say that have complained about it in the past and nothing was ever done about it.

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Ours all have face sheets. I was going to suggest printing a new one from the computer, but I guess you don't have that option! Frustrating!

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I've never heard of such a thing. I'm wondering if someone had to make a copy of said face sheets and then put them back in the wrong spot. Where I work, some nurses will pull all the stuff out to make copies when a res is being sent out and then just dump all the papers in the "to be filed" bin for the secretary. Just lazy....

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Specializes in retired LTC.

I really can't fathom a chart without a face sheet! What do you send out with the ambulance or to the hospitals?!? Face sheets have insurance info, but more importantly, the family/responsible party info (and usually the religion and funeral home info).

Just FYI, I have known attending MDs take a face sheet as their reference/admission info sheet. And they take the last sheet.

I have 2 suggestions. Since your Lab Service is complaining, I would bring that up to mgt explaining their SS# requirement. That and the need for the other info is absolutely nec.

But then the second part of my suggestion is that you will need to provide a list to medical records/admissions of all your missing face sheets. And I would do that regardless. You really do need to concretely address the problem again - you have no real way of figuring out who did what other than 'complain'...

As an interim measure, when we rec'd late admissions without face sheets, we would copy the hospital's transfer face sheet. It would have all the info, esp the family info, I needed temporarily. There were times I had to send a new admission right back out for instability and I could then notify family as approp. Another recourse might be to check overflow charts if they still stay on your floor ----

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Yes it is shocking that so many charts have no face sheets. In fact, there was an emergency recently and I heard the RN nursing manager say "I guess he has no face sheet. I guess we'll have to just send him out with his MAR, TAR and other stuff instead". So I guess if the patient dies at the hospital, the hospital staff will have no next of kin to call, no funeral home and no social security number to use to even fill out the death paperwork properly. Unbelievable!!!!!!

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Specializes in LTC, Hospice, Case Management.
Yes it is shocking that so many charts have no face sheets. In fact, there was an emergency recently and I heard the RN nursing manager say "I guess he has no face sheet. I guess we'll have to just send him out with his MAR, TAR and other stuff instead". So I guess if the patient dies at the hospital, the hospital staff will have no next of kin to call, no funeral home and no social security number to use to even fill out the death paperwork properly. Unbelievable!!!!!!

Have you went to the DON or Administrator about this concern?

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Blackcat, you seem to work at a rather troubled facility....

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Yes, I work at the "Anything Goes" LTC facility. The CNA's are in charge at this facility. The RN supervisors let them run the place. The RN supervisors are well aware of the missing face sheets. I was told by the other nurses that management is aware of the missing face sheets but still nothing is done about it. At the next staff meeting, I will ask about the "missing face sheets."

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Specializes in LTC, Hospice, Case Management.
Yes, I work at the "Anything Goes" LTC facility. The CNA's are in charge at this facility. The RN supervisors let them run the place. The RN supervisors are well aware of the missing face sheets. I was told by the other nurses that management is aware of the missing face sheets but still nothing is done about it. At the next staff meeting, I will ask about the "missing face sheets."

Ahh, but I didn't ask if you went to the RN supervisors. I asked if you had informed the DON or administrator. Don't wait for the next meeting. ;)

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