documenting

DDdove, LPN · Feb 27, 2011

No omg no. CNAs get ****** when we get vital-crazy(which happens when theres a flu/virus that goes around)
You document on a resident by your facilities policy. Not each shift on every patient.(Theres not enough trees in the world to make paper to do that lol).

:) Thanks

Is this good for documenting on endotracheal suctioning?

Endotrachial suctioning given via sterile technique d/t to visual secreations. Pt tolerated well.

Or should I discribe proceedure more like putting in, (pt hyperoxygenated before, during and after proceedure.)

Chin up · Feb 27, 2011

I am confused on what to document on. I know I document PRN meds such as pain, ATB but do I document in nurses notes a nightly assessment such as "Pt sleeping throught out night with no complaints. 0600 meds passed, no compaints or needs stated." I heard you assessed pt every shift for medicare but what if there is nothing happening? And if barrier cream is applied at night by CNA do we document "barrier cream applied"? Another is if the client wanders out of their room at night and then goes back to bed do you say "resident wandering, self redirected back to bed"? or not even document it. I feel so stupid.

Kudos for asking, you obviously aren't stupid! Usually, there is a document with the names of residents who are on Medicare and need notes. It has the room number, name, and dx. It may even tell you how many days of documentation is needed. Or, you should have a report sheet, or 24 hour log that also tells you, whom to document and when Such as ABT, change in condition or fall. These are just examples, but helpful tools all nurses need to remember who, what and why to document. Some facilities have stickers on the chart, say green dot, for Medicare notes or red, with ABT written on it. So when you scan the charts, you see immediately, who needs a note. Again, these are helps and sometimes they are not there, forgotten or have fallen off. As you work throughout the night, jot down on your report (census sheet) what you did, ie, 2am ^congestion noted. O2 sat 88% on 2L. Suctioned x1 vi trachea with 60cc of clear, sl thick, drainage removed. Resident clear, repeat o2 sat93%. O2 at two liters via mist mask resumed, treatment tolerated well. Resident repositioned and comfortable at present. Will continue to monitor resp. status. This is just a small example. It is already assumed sterile technique was used, so I don't write it. But it never hurts to over write, except time. You will learn to write only what is necessary and not a book. Yes, look at the better notes to see how they are worded. This is not the same as copying. That nurse may have had green drainage, and you would not write that. Eventually, you will be flying through your notes. But that takes time, so be kind to yourself. Medicare requires a note per day, if you miss one, it is not the end of the world. Hopefully you won't as notes cover us when things happen, but some nights other things are priority, including other notes. Just be sure during report, to get as much info as you can, this will help tremendously. Some notes Must be done every shift, but between you and me, everyone forgets sometimes.

Oh, you don't need to write CNA care, they have ADL sheets for that. Only document what you did and don't repeat if you already have written something down on say, a flow or treatment sheet, unless absolutely necessary. You can also ask SDC, MDS or MMQ to review the facilities documentation policy with you. You are new, learning tons, and should be guided gently by your coworkers and managers. Have fun with it, don't stress about it, we have all been there! Peace!

DDdove, LPN · Feb 28, 2011

Kudos for asking, you obviously aren't stupid! Usually, there is a document with the names of residents who are on Medicare and need notes. It has the room number, name, and dx. It may even tell you how many days of documentation is needed. Or, you should have a report sheet, or 24 hour log that also tells you, whom to document and when Such as ABT, change in condition or fall. These are just examples, but helpful tools all nurses need to remember who, what and why to document. Some facilities have stickers on the chart, say green dot, for Medicare notes or red, with ABT written on it. So when you scan the charts, you see immediately, who needs a note. Again, these are helps and sometimes they are not there, forgotten or have fallen off. As you work throughout the night, jot down on your report (census sheet) what you did, ie, 2am ^congestion noted. O2 sat 88% on 2L. Suctioned x1 vi trachea with 60cc of clear, sl thick, drainage removed. Resident clear, repeat o2 sat93%. O2 at two liters via mist mask resumed, treatment tolerated well. Resident repositioned and comfortable at present. Will continue to monitor resp. status. This is just a small example. It is already assumed sterile technique was used, so I don't write it. But it never hurts to over write, except time. You will learn to write only what is necessary and not a book. Yes, look at the better notes to see how they are worded. This is not the same as copying. That nurse may have had green drainage, and you would not write that. Eventually, you will be flying through your notes. But that takes time, so be kind to yourself. Medicare requires a note per day, if you miss one, it is not the end of the world. Hopefully you won't as notes cover us when things happen, but some nights other things are priority, including other notes. Just be sure during report, to get as much info as you can, this will help tremendously. Some notes Must be done every shift, but between you and me, everyone forgets sometimes.
Oh, you don't need to write CNA care, they have ADL sheets for that. Only document what you did and don't repeat if you already have written something down on say, a flow or treatment sheet, unless absolutely necessary. You can also ask SDC, MDS or MMQ to review the facilities documentation policy with you. You are new, learning tons, and should be guided gently by your coworkers and managers. Have fun with it, don't stress about it, we have all been there! Peace!

Thank you very much :)

CapeCodMermaid, RN · Feb 28, 2011

:) Thanks
Is this good for documenting on endotracheal suctioning?
Endotrachial suctioning given via sterile technique d/t to visual secreations. Pt tolerated well.
Or should I discribe proceedure more like putting in, (pt hyperoxygenated before, during and after proceedure.)

Visual secretions? You suctioned her eyes? :eek: :clown:

No need to describe HOW you suctioned. It is assumed you followed the standard of practice and your facility's policy and procedure.

DDdove, LPN · Mar 9, 2011

haha :clown:funny By the way I loved your LTC texting too

Nascar nurse, ASN, RN · Mar 9, 2011

Visual secretions? You suctioned her eyes?
No need to describe HOW you suctioned. It is assumed you followed the standard of practice and your facility's policy and procedure.

Funny. I took it she had to do the procedure BECAUSE OF the visual secretions...like was she crying?? (Also meant to be a funny because we all chart something silly at one time or another).

CapeCodMermaid, RN · Mar 9, 2011

We had a doctor once write an order to "discontinue all oxygen". I asked him if he wanted us to smother the woman since we all need a certain amount of oxygen as human beings. He turned bright red and then told me to write the order the way I wanted it. "Discontinue all SUPPLEMENTAL oxygen." We all write things in a hurry that later on make us cringe. I'm with the poster who wrote you should be able to look at your documentation 3 or 5 years later and still understand what was done.

Finallydidit · Mar 9, 2011

Just a few things I try to include..

If Resident complains of anything.. ie: headache.... chart what you did to fix it and when it was effective..

Res complain of headache pain 4/10, PRN pain medication given, eff. @ 1/hr

Also if a Resident is constantly non-compliant with care or meals, make sure that you document that the MD and family are aware of the situation. ie: Diabetic diet

Res. non complient with diet orders, comsumes candy bars and sodas several times a day, MD and family are aware of behavior

If documenting a new skin tear, along with a detail of what happened, I describe the wound, and then just add, cleaned and treated according to company protacals.

Think of it like this... They pretty much want to know the issues and why they need to be there. So make sure to tell them.. They also want to know what you are doing to fix the issues and if they are making progress or declining, so make sure you tell them that too. If they are not making progress, (non complient with orders, diet, therapy etc.) Tell them what has been reported (to Mds, family) so they know its out of your hands and being further evaluated

morningmom · Mar 17, 2011

I figured I'd put in my .02 and tell you what I would do.

Skilled/medicare residents have a full head to toe q 24 hours. Each shift splits up the resdients and it rotates that way each shift does not do the same resident every day (with the exception of one day d/t the odd number of days) The head to toe has it's own form so you do the assessment and fill in the form. If you are not doing the assessment on a resident, then you have to do a nurses note on that resident. We did not need to do a note if we did the assessment.

I worked nights, and if I had no problems with a resident my nurses note would say something along the lines of

"Resident lying in bed quietly with eyes closed at this time. Resps even and unlabored. 0 s/sx of pain, discomfort or distress. Urinary incontinence care provided by staff x2 with 2 assist thusfar this shift without any difficulty. Midnight medications administered without difficulties. Resident friendly and cooperative with care thus far this shift." Then I would add something that would be individualized...like incision description, etc.