Documentation suggestions

Emart · Aug 13

Is this a good example for daily Progress Notes? Any suggestions welcome.

Nurse's Notes

The resident is resting comfortably in bed, with fall precautions properly implemented. The call light is within easy reach, and the resident shows no signs or symptoms of pain or distress. The resident is alert, oriented to person, place, and time, and remains in stable condition. All prescribed medications have been administered as per the physician's orders and were well tolerated. Assistance with activities of daily living was provided by the CNA.

The IV access site is patent with no signs of infection or infiltration. The O2 nasal cannula is positioned correctly, and the resident is maintaining adequate oxygen saturation levels. The NG tube is secured in place, with no signs of displacement or discomfort noted. The Foley catheter is draining clear urine, and there are no signs of blockage or infection. The colostomy site is clean and well-maintained, with the stoma appearing healthy and the appliance securely attached.

Emart · Aug 13

Is this a good progress note for a patient transfer to a Hospital? Any suggestions...

CNA reported to me that the resident had three episodes of coffee ground emesis this morning. The resident was checked in the room and was sitting in a wheelchair. I transferred the resident to bed from the wheelchair and elevated the head of the bed to 45 degrees. I repositioned the resident to the right side to prevent aspiration. Vital signs were as follows: BP 120/80, P 88, Temp 98.6, Resp 18, O2 98%. The resident complained of stomach discomfort. I called Dr. X and reported the condition, and he ordered the transport of the resident to X hospital via regular ambulance. I called Maria, the resident's daughter, and informed her of the condition and the order to transfer the resident to hospital. I explained the Bedhold policy, and she understood. I called ABC Ambulance for transport. I called X hospital, spoke to nurse Betty and gave her report about the transfer and the condition of the patient. The ambulance arrived at 1400, picked up the resident, and left via stretcher accompanied by two paramedics. Safety and comfort were maintained.

Emart · Aug 13

Is this a good example for discharge documentation?

I met with resident and explained discharge instructions and medication list. Resident verbalized understanding. Call received from daughter and explained all discharged instructions as well. Daughter verbalized understanding. At time of discharge resident was stable and had no complain of pain or discomfort. Resident discharged home with Home Health Services, HHA/RN/PT/OT, Prescriptions and all personal belonging . Resident is encouraged to follow up with PCP. in one week of discharge. Resident was assisted by CNA until resident reached to their transportation. (Family car) Family expressed satisfaction with their stay in the facility.

Editorial Team / Admin · Aug 13

The best place to ask questions related to documentation is going to be your facility's resources: policy/procedure, educator, and leadership teams. What may be a "good example" for my employer may be totally different than what your employer requires.

JKL33 · Aug 13

I agree with the above. I will say those sounds like decent basic examples with the caveat already given above. A specific thing I would add to your hospital transfer template is the condition and vitals of the patient at or very near the time of departure which may be the same or different than what you already noted upon your initial assessment of the situation.

In addition to noting relevant patient assessment and care given, it is generally important to address the items your employer specifies (you did include examples of these such as "belongings inventoried”—just make sure once you have your basic template you compare it against employer policies for things to include).

Also remember to avoid double-charting whenever possible. It wastes your time and can introduce other problems.

Good luck!

allnurses Guide · Aug 14

What system are you using?

Emart · Aug 15

PCC - point click care

FolksBtrippin, BSN, RN · Aug 15

Please take with a grain of salt because I don't work in LTC. But seems okay to me. I would leave out "vital signs within normal limits" when you are documenting the values. And I agree that a set of vital signs before transfer to hospital is best. Is there a separate skin assessment with measurements? Because I would definitely measure rashes and pressure injuries on admission, unless you have a wound care nurse that does it? If you have done that somewhere else, it may be helpful to simply refer to that in your narrative. "See skin assessment, significant for multiple rashes and wounds.” Or "Skin assessment unremarkable.”

allnurses Guide · Aug 16

FolksBtrippin said:

Please take with a grain of salt because I don't work in LTC. But seems okay to me. I would leave out "vital signs within normal limits" when you are documenting the values. And I agree that a set of vital signs before transfer to hospital is best. Is there a separate skin assessment with measurements? Because I would definitely measure rashes and pressure injuries on admission, unless you have a wound care nurse that does it? If you have done that somewhere else, it may be helpful to simply refer to that in your narrative. "See skin assessment, significant for multiple rashes and wounds.” Or "Skin assessment unremarkable.”

I would also add that on admission we never said a wound was a pressure injury. We wound describe it aand let the physician stage it.

kbrn2002, ADN, RN · Aug 19

hppygr8ful said:

I would also add that on admission we never said a wound was a pressure injury. We wound describe it aand let the physician stage it.

If state regulations and/or facility policy does not allow for an RN to stage and document a pressure injury I would still describe any potential pressure areas in admission charting. This limits the possibility that the LTC will be dinged for a facility acquired pressure injury