Documentation troubles

[RNinRI]

Hi everyone,

I didn't know what forum to put this in, doesn't quite fit pediatrics. I work for a childrens residential shelter for abused and neglected children. We also take in kids who have behavior issues and are removed from their homes if the parents can't handle them. Is there anyone out there who works for a similar type of agency who can share what type of documentation you use for following the kids' care? We are trying to streamline our documentation and make it more user-friendly while also following DCF standards. We are all set with MARs. It's just the daily documentation we need help with. Right now everything is too spread out and we are trying to consolidate the paperwork, if possible! I'd appreciate any help you can give me!

Thank you!

[RNGrammie]

i work for a "children's home" in upstate ny. we, as nurses, document mars when giving meds. we give the meds on the "dorms" (5 of them)...the mar notebook is left there. in our clinic, on campus, we have a "chart" for each resident. we document anything nursing we do for the kids. check them for illnesses, after restraints, physicals....basically, anything we (nurses) see the kids for, it's put on our daily log....kids name, time and complaint....then noted in the nurse's note in their chart. each dorm has a log book that is used to log the daily stuff on the dorm. hope this helps..

[RNinRI]

Thank you for replying. Your system sounds similar to what we use. I was just looking for ways to streamline and simplify but I'm not coming up with anything better!