Documentation

payang0722 · May 18, 2011

I'm a new LVN, just 5 days on the floor myself. But in our facility, we have to chart on that behavior and make a care plan and monitor it.

Let's wait for the rest of the nurses who have a lot of experiences to reply. Good luck to us!

NurseLoveJoy88, ASN, RN · May 18, 2011

I think we have to be careful on what we say in our charting. As long as your charting is objective and states your assessment and your intervention then you should be fine.

For example instead of writing "Resident was agitated and combative" It should be " Resident was observed doing x,y,z"

Is it possible that your boss want to make sure the nurses' charting is done correctly?

If she doesn't want you to chart anything then I would be very suspect of that.

I always chart behavioral problems no matter what, this is especially helpful in determining the plan of care for the resident.

It is also helpful for pysch to come in and development diagnosis and treatments based off of our documentation.

Brea LPN · May 18, 2011

I have been a nurse for one year, but I have dealt with a lot of behavior issues in that year. I've been told to any chart any occurrences in case a psych consult is needed. If it isn't charted, then the behavior occurrences never even happened.

tyvin, BSN, RN · May 18, 2011

Your place should have behaviour sheets to monitor patients who start or are admitted with behaviours. Where I worked when ever we wanted to track behavior for possible psych, Dx, eval or request meds that is the tool we used. It was just a generic form that we would put in the chart and make a section for behaviour.

Other then that of course you chart behaviour if it deems documentaion.

merlee · May 18, 2011

The above posters are all correct. "If it wasn't charted, it wasn't done" applies here to. And as earlier stated, state what you saw and heard. "pt was mumbling while walking down the hall, and began to hit himself when this nurse asked what was wrong this evening"

Be objective, do not label the activities. "Just the facts, m'am!"

Keep in mind that charting assists in developing the pt's care plan, and also helps in determining how much time you are spending with your patients.

Best wishes!

caliotter3 · May 18, 2011

I once was given this advice by an emperienced nurse: "If you're not going to do anything about something, then you should not chart it". Makes sense to me, if you see a behavior or a situation, then you should act upon it, if you are going to chart about it. Otherwise, you are leaving yourself open to criticism for not taking action.

debRN0417 · May 18, 2011

If the resident is receiving psychotropic medications, then you need to have a reason to administer them, or change doses, or be able to say that their behavior is controlled on what they are receiving. Please document all behaviors. A lot of facilities have a behavior monitoring sheet with the MAR that they can document the behaviors. It is in the best interest of your resident in order to make sure they are getting the medications and treatments they need...or be able to attempt a dose reduction so that they do not have to take a bunch of meds forever. Unfortunaately some may need them forever, but how will you know unless you are documenting the behaviors? Those behaviors, or no behaviors help justify the use of the medications. Also if they are uncontrollable, it will help you (hopefully) get them out of your facility (not holding my breath). Just because a resident is not exhibitng behaviors does not mean they do not need medications. Whatever they're on is controlling it...unless they're too sedated.

Whispera, MSN, RN · May 18, 2011

If you chart something and no one does anything about it, then if the state comes in and audits charts, your facility will be in trouble.

If you see something that could be made-better in a patient and don't chart about it, then maybe no one else will see it either, and nothing will be done. In my opinion that omission is not acting in the best interest of the patient.

I agree though....just the facts. Don't interpret behavior by putting a label on it. Just state what you observe.

classicdame, MSN, EdD · May 18, 2011

your DON may have experienced some bad charting from other nurses over the years. We had a nurse recently who charted something negative about another nurse - really inappropriate. Basically, if you observe a NEW behavior, or one that is potentially unsafe for the resident or others, then it needs to be charted and you need to intervene.

morte, LPN, LVN · May 18, 2011

I once was given this advice by an emperienced nurse: "If you're not going to do anything about something, then you should not chart it". Makes sense to me, if you see a behavior or a situation, then you should act upon it, if you are going to chart about it. Otherwise, you are leaving yourself open to criticism for not taking action.

I would hazzard a bet, this is what the DON is concerned with.

I have told nurses for years, if you KNOW it isn't going to get done, DON"T care plan it. You will look worse for not doing what you said you where going to, than not careplanning it.....this is not for major things, obviously.

chiandre · May 18, 2011

always remember that every problem you document must have objective data, your nursing interventions, patient response, and your nursing follow-up. to omit information, especially a problem, from a patient's chart is unethical and illegal. as a registered nurse, it can come back to haunt you especially if the problem is a prelude to a more sinister problem. when in doubt, call your risk manager for assistance.