Documentation after shift ended

michiganmark_rn · May 7, 2011

Depends on how many admissions/discharges I get but typically I'm done on time but it's taken me a year of building and refining my organizational skills enough. I work the 7-3 shift, I usually arrive about 10 minutes early and gather up the paperwork stuff I'm going to need (blank vital sheet for my cna's, skin assessments for the day, census sheet, cna assignment) and unpack my supplies. I keep a wrist bp cuff, thermometer, pulse ox, steth, scut monkey and davis drug guide on my med cart. From 7-7:30 I get shift to shift report, write out my vital list and check the bowel book looking for residents that'll need a prn dose of MOM. I then quickly sort the stock meds so they're easy to find, get fresh apple sauce and water and at 8am I hit the hallway rolling working on my 9am pass. I don't stop, I don't chase residents - if they are in the room, they get meds and one slash across their name, if they don't, they don't earn a slash. Those few residents that only have one med pass time earn two slashes and are "done" with meds except prns. The ones that don't 'earn their slash' I'm going to catch as they leave the dining room before they go off to activities or rehab or whatever. I usually have enough time after my first cruise down the two hallways to flag my treatment book for later. As they leave the dining room, the ones without their first slash get their am meds and earn their first slash and my 9am med pass is usually finished by 9:45 or so. My next meds are a mix of 12noons and 2pms so I now have time for skin assessments and treatments. I do as many as I can before 11am when I do noon meds. 11:30 or so is a luxurious 1/2 hour lunch and then an hour of charting, phone calls and tasks. 1pm I start 2pm meds whether all my charting is done or not (usually not). I finish meds, finish up treatments and then retire to the desk to finish up charting. Most time I have charting done by 2:45pm so I lounge around the med cart, emptying my trash, restocking, wiping it down. To me, med pass is what killed my speed for a long time, especially looking up meds with the big drug books. Scut monkey has the info I need most of the time and after a year, very few patients are on meds I haven't seen before. I've tried many, many shortcuts - none of them work. I've tried flagging my MAR before pass and unflagging as I go, I've tried flagging my 2nd med pass if they have meds when I do first, I've tried labeling med cups - slashes are the quickest and have been foolproof for me. My charting speed has also increased with time and there is a rhythm to it that insures you write down everything you wish to convey. I don't go searching for charts that are out of the rack until all my other charting is done. Most of the time the dietitian or mds or whomever will have it returned before I finish the other charting. Don't ever chart when your stressed, it's a time waster and what you write is in there forever. When I started, I would be stuck charting for sometimes 2 hours after my shift and would leave flustered and feeling like I wasn't very effective. A year later, it's much better and I love LTC and am glad I chose this over hospital nursing.

txdon · May 7, 2011

Very informative post! I am impressed with your organization skills and how you've found a system that works for you. When you speak of slashes, are you referring to slashes on a separate sheet of paper? Is that something you created? Also, how many residents do you take care of on your unit? What number of residents do you feel is manageable and how many cna's do you have working for you?

blondesareeasy · May 7, 2011

We've had a night shifter here until 1400l.

Forever Sunshine, ASN, RN · May 7, 2011

Depends on how many admissions/discharges I get but typically I'm done on time but it's taken me a year of building and refining my organizational skills enough. I work the 7-3 shift, I usually arrive about 10 minutes early and gather up the paperwork stuff I'm going to need (blank vital sheet for my cna's, skin assessments for the day, census sheet, cna assignment) and unpack my supplies. I keep a wrist bp cuff, thermometer, pulse ox, steth, scut monkey and davis drug guide on my med cart. From 7-7:30 I get shift to shift report, write out my vital list and check the bowel book looking for residents that'll need a prn dose of MOM. I then quickly sort the stock meds so they're easy to find, get fresh apple sauce and water and at 8am I hit the hallway rolling working on my 9am pass. I don't stop, I don't chase residents - if they are in the room, they get meds and one slash across their name, if they don't, they don't earn a slash. Those few residents that only have one med pass time earn two slashes and are "done" with meds except prns. The ones that don't 'earn their slash' I'm going to catch as they leave the dining room before they go off to activities or rehab or whatever. I usually have enough time after my first cruise down the two hallways to flag my treatment book for later. As they leave the dining room, the ones without their first slash get their am meds and earn their first slash and my 9am med pass is usually finished by 9:45 or so. My next meds are a mix of 12noons and 2pms so I now have time for skin assessments and treatments. I do as many as I can before 11am when I do noon meds. 11:30 or so is a luxurious 1/2 hour lunch and then an hour of charting, phone calls and tasks. 1pm I start 2pm meds whether all my charting is done or not (usually not). I finish meds, finish up treatments and then retire to the desk to finish up charting. Most time I have charting done by 2:45pm so I lounge around the med cart, emptying my trash, restocking, wiping it down. To me, med pass is what killed my speed for a long time, especially looking up meds with the big drug books. Scut monkey has the info I need most of the time and after a year, very few patients are on meds I haven't seen before. I've tried many, many shortcuts - none of them work. I've tried flagging my MAR before pass and unflagging as I go, I've tried flagging my 2nd med pass if they have meds when I do first, I've tried labeling med cups - slashes are the quickest and have been foolproof for me. My charting speed has also increased with time and there is a rhythm to it that insures you write down everything you wish to convey. I don't go searching for charts that are out of the rack until all my other charting is done. Most of the time the dietitian or mds or whomever will have it returned before I finish the other charting. Don't ever chart when your stressed, it's a time waster and what you write is in there forever. When I started, I would be stuck charting for sometimes 2 hours after my shift and would leave flustered and feeling like I wasn't very effective. A year later, it's much better and I love LTC and am glad I chose this over hospital nursing.

Next time I work I'm going to try your slashing method. Ive been on the job a year too and flagging is taking up too much time for me.

To OP. I usually require a half hour to chart. Sometimes longer if its a busy night. Sometimes I'm lucky and get out right at the end of my shift.

michiganmark_rn · May 7, 2011

Very informative post! I am impressed with your organization skills and how you've found a system that works for you. When you speak of slashes, are you referring to slashes on a separate sheet of paper? Is that something you created? Also, how many residents do you take care of on your unit? What number of residents do you feel is manageable and how many cna's do you have working for you?

My unit prints us census sheets organized by med cart with resident names on the left by room number and space for report/notes to the right. Equipment info is already included so body alarms, low beds, fall mats are already included. I put one slash through the room number first pass, two when I finish second pass. My CNAs have 9 residents each typically and are the hardest working and most compassionate men and women you'll ever meet. I have between 25 and 30 residents if I do a set that has both ltc and rehab or 30 if it's strictly ltc. The things I've learned is besides the DON, YOU are the busiest person in the building. Don't wait around for people or charts, use your resources and calmly move forward. There is no magic number to managable amount as we all know one extremely disruptive resident can throw your day off. I know when I first started 30 residents KILLED me and I finished late, was frustrated and stressed and just not enjoying life.