So, I am not sure who is familiar with how electronic documentation works in SNF settings. However, as a brief explanation, in our facility, nurses mainly have two sets of "charting" that they are documenting on: the MAR (medication administration record) and the TAR (treatment administration record).
MAR documentation is pretty straight forward as you are just charting on medications you have administered. You basically state yes that you gave them or no, such as patient refused, vital signs were outside of parameters, or patient was unavailable.
However, the correct way of documenting on the TAR seems to be more open to interpretation.
For example, many of our patients will have orders such as "Call 911 if resident is having chest pain, shortness of breath, increased weakness or any other concerns." There are two options: you can chart 'yes' or 'no.' For most nurses, they will chart "yes" to such orders even if they didn't call 911 with the explanation: "We are just acknowledging that should the patient have had these symptoms we would have called 911." HOWEVER, we have a nurse that likes to chart on each and every order: "Resident did not have symptoms. Therefore, 911 was not called." This is technically correct. However, it does create a lot of unnecessary progress notes.
Any thoughts on which is the best charting method? If you chart yes to calling 911 and you didn't, it could be argued that this was falsification of documentation. However, if you write 911 was not called every time you don't call 911, you're creating a lot of progress notes that don't need to be made.
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So, I am not sure who is familiar with how electronic documentation works in SNF settings. However, as a brief explanation, in our facility, nurses mainly have two sets of "charting" that they are documenting on: the MAR (medication administration record) and the TAR (treatment administration record).
MAR documentation is pretty straight forward as you are just charting on medications you have administered. You basically state yes that you gave them or no, such as patient refused, vital signs were outside of parameters, or patient was unavailable.
However, the correct way of documenting on the TAR seems to be more open to interpretation.
For example, many of our patients will have orders such as "Call 911 if resident is having chest pain, shortness of breath, increased weakness or any other concerns." There are two options: you can chart 'yes' or 'no.' For most nurses, they will chart "yes" to such orders even if they didn't call 911 with the explanation: "We are just acknowledging that should the patient have had these symptoms we would have called 911." HOWEVER, we have a nurse that likes to chart on each and every order: "Resident did not have symptoms. Therefore, 911 was not called." This is technically correct. However, it does create a lot of unnecessary progress notes.
Any thoughts on which is the best charting method? If you chart yes to calling 911 and you didn't, it could be argued that this was falsification of documentation. However, if you write 911 was not called every time you don't call 911, you're creating a lot of progress notes that don't need to be made.