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

[chiuli]

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

[CoffeeRTC, BSN, RN]

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.

[Trubie, LPN]

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!

[indigonurse]

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]

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?

[indigonurse]

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]

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

[indigonurse]

"Documentation—The process of recording information in the medical chart, or the materials in a medical chart." This does not differentiate between "narrative charting" or simply charting that a routine, or prn med was given on a MAR. MAR's are part of the res. chart.

[CapeCodMermaid, RN]

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

This is about writing a nurse's note, NOT signing off the MAR.

[CloudySue]

In my facility, we've always charted by exception. About two weeks ago we got a new acting DON and she's all hot on documention, she has a rotating schedule where each shift is responsible for documenting on 1/3 of the residents on the floor every shift. We all get a certain block of rooms to write about, then the next week each shift gets another block of rooms. It is certainly becoming a boring narrative day after day for our more stable, predictible residents: "Resident A&Ox3, VSS, no c/o pain/discomfort, ambulates ad lib w walker w steady gait, all meds/tx as ordered, good meal completion, participates in planned activities." I understand completely the importance of nurses' notes, but reporting when there's nothing to report is such a time-waster. This is just the latest of a never-ending list of pointless tasks which divert our precious time away from ACTUALLY PROVIDING DIRECT CARE TO RESIDENTS.

[actioncat]

In my facility, we've always charted by exception. About two weeks ago we got a new acting DON and she's all hot on documention, she has a rotating schedule where each shift is responsible for documenting on 1/3 of the residents on the floor every shift. We all get a certain block of rooms to write about, then the next week each shift gets another block of rooms. It is certainly becoming a boring narrative day after day for our more stable, predictible residents: "Resident A&Ox3, VSS, no c/o pain/discomfort, ambulates ad lib w walker w steady gait, all meds/tx as ordered, good meal completion, participates in planned activities." I understand completely the importance of nurses' notes, but reporting when there's nothing to report is such a time-waster. This is just the latest of a never-ending list of pointless tasks which divert our precious time away from ACTUALLY PROVIDING DIRECT CARE TO RESIDENTS.

Amen to that. Sounds like she cares more about the paperwork and how it looks to state rather than the actual people living there!