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

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!!!

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.

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??

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.

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

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.

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.

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.

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....

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.