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Do you have to make a nurses note on every patient?

Posted
chiuli chiuli (Member)

In a nursing home setting, I know I dont have to chart on every patient especially if nothing happened. But what exactly do you chart/ don't chart? If a patient says they feel a little constipated because they only went a little this morning, do you chart that? Especially if there were no interventions.

Also, a lot of times the nurses tell me to chart for them. They say, "just make a note on Mrs X and write that she had a headache was given tylenol at 4pm. " But Im not sure if Im supposed to chart for her, what if she gave the wrong dose and something went wrong? It would fall on me

My supervisor told me one time that if you don't do an intervention, then do not chart. In the case of your post, this advice can be taken two ways. If the other nurse gave the tylenol, then it is for her to chart on it. Do not chart that you gave a med when someone else gave it, that is a no no. And if nothing out of the ordinary was done for your resident in response to an assessment or complaint, you do not have to chart on that resident for the shift. The only residents we were required to chart on were the alert charting people and the weekly summary people. Anything else is extra. Policy may be different at your facility.

Caffeine_IV

Specializes in LTC, med/surg, hospice. Has 7 years experience.

When I worked in LTC we only HAD to chart on certain patients...maybe Medicare ones? I don't remember at this moment.

I did chart certain events especially on residents that were not DNRs.

Some patients hadn't had a nurse note in over a year!!!

cebuana_nurse

Specializes in OB, Peds, Med Surg and Geriatric Nsg.

In my facility before, its a must to chart on Medicare patients though I agree with caliotter3 that if you didn't do an intervention, then there's nothing to chart.

MassED, BSN, RN

Specializes in ER. Has 15 years experience.

yes. At the minimum "assumed care of patient, report received from such and such nurse... pt remains without CP, sob - noted pedal edema 2+, pt a/ox3, resp rate even and unlabored..." or something to that effect. What would stand up in court if you don't write a note, at least proof that you were there, assuming the role of nurse for that patient, and how you saw them and their status. What if they had a stroke, fall, or heart attack while you were caring for them, and you did not note anything?? What would happen should you need to defend yourself??

Hospice Nurse LPN, BSN, RN

Specializes in LTC, Psych, Hospice. Has 15 years experience.

Never chart something you didn't do! When I worked in LTC, we had "weekly charting" so that something was written on each pt every week. Of course, if something unusual happened, we would chart that right away. Check with your facility.

OttawaRPN

Specializes in acute care med/surg, LTC, orthopedics. Has 5 years experience.

In LTC the flow sheets the HCAs fill out is sufficient for the ADL stuff, and the MARS for any meds but any progress notes I did was by exception only.

Never chart for anybody else, remember these are legal documents you're using.

I always say to myself, its better to write something than nothing. But then again, if the person has a stroke, it that really the nurses fault? It can happen abruply without any signs

kakamegamama

Specializes in MCH,NICU,NNsy,Educ,Village Nursing.

I always say to myself, its better to write something than nothing. But then again, if the person has a stroke, it that really the nurses fault? It can happen abruply without any signs

True, a stroke can happen abruptly.And, a patient's stroke is not the nurse's fault. However, if you don't chart what interventions you performed in that moment/those moments following, when you found the patient, etc., how will any one know? Were there changes in the patient compared to the norm for that patient? If so, when were they noticed, etc. Those types of things. That way--there is documentation of the changes in the patient, etc.

CapeCodMermaid, RN

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience.

MassED....this is LONG TERM CARE. There is no way any nurse would be able to write a note like that on every resident. We chart on Medicare residents every shift and if someone has an event...regardless of their code status.

And....if someone says they are constipated, you SHOULD have some sort of intervention.

Nascar nurse, ASN, RN

Specializes in LTC & Hospice. Has 35 years experience.

yes. At the minimum "assumed care of patient, report received from such and such nurse... pt remains without CP, sob - noted pedal edema 2+, pt a/ox3, resp rate even and unlabored..." or something to that effect. What would stand up in court if you don't write a note, at least proof that you were there, assuming the role of nurse for that patient, and how you saw them and their status. What if they had a stroke, fall, or heart attack while you were caring for them, and you did not note anything?? What would happen should you need to defend yourself??

You must have missed the first line of the OP..."in a nursing home setting". We do not chart every day on every resident in LTC. Unrealistic and unnecessary.

Sparrowhawk

Specializes in LTC.

I'd ask your facility....you chart on weekly charting, monthly charting, anytime someone falls, bruise, skin tear, new orders, sent to hospital, comes back from hospital, anything SIGNIFICANTLY different with said resident, when anything changes from the normal....

CoffeeRTC, BSN, RN

Has 25 years experience.

Back up to that contipated reisident and lets think this thru...Constipation in the elderly/ LTC resident can be an sentinal event when it becomes an impaction. (google that) That is a bit no no. So when the state is reviewing the chart and finds no interventions or documentations to prevent a problem that you knew about...it isn't going to be nice.

When in doubt document.

and no...not every ltc pt is documented on daily.

I generally chart....

Medicare

antibiotics during treatment and 3 days post

new admits 3 days post

any incident report and 3 days post

anything a CNA reports to me that needs assessment (change in status, skin condition)

any reports of pain that require PRN medication

anything I call the doctor about

new orders/dc'd orders

upcoming appointments/transport details

monthly summaries

and more!

In LTC we do not have to make a note in all the res. charts every shift. But, we do chart on them every time we admin a med, or tx, per facility policy if a res. has a change of condition, weekly according to policy (there is usually a schedule for this) if res. are on medicare (there is usually a schedule for this).

CapeCodMermaid, RN

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience.

If you charted on a resident every time you gave a med, you'd be charting on ALL of them every day. They all get meds. Did you mean PRN med?

everytime we admin. a med we do chart on them even if it is just putting our initials in a box to chart that we admin. it

CapeCodMermaid, RN

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience.

I'm pretty sure the discussion on charting referred to writing a narrative nurse's note...NOT initialing an MAR.