Example of weekly summary LTC

weekly summary is usually dictated by the state regulations but what specifically written is not mandated. I think it just says something about update/progress/decline of status.How I do mine; go through the care plan and address the goals on each problem or care plans hopefully by doing that you have addressed all the problem--at least active problem or diagnosis. Hope this helps.

EX:

alert and oriented x 3, right hemiparesis noted secondary to recent CVA. Moves right arms to shoulder level. continue with the use of oxygen at 2 liters/minutes saturation 93% currently on cipro 250 mg twice a day for pneumonia. denies of SOB, no coughing observed. Encourage use of incentive spirometer throughout the day lung sounds with crackles to the bases.Requires extensive one person assistance with transfers, bed mobility etc. etc.

It helps but what meds do u cover on ur weekly? Just antipsychotic, hypertensive, cardiac but what else? I have been including alot more and my charting is to in depth. I start with alert & oriented at baseline. No c/o pain or discomfort. Lungs Cta with no SOB, dyspnea, or cyanosis noted. Respirations even/unlabored. O2 sat 97% RA bs active 4 quads abd soft non tender with no distention noted. Last BM. Perrla. Hrr. Skin turgur good. Skin clean dry intact. Residents diet. Minimal asst with ambulation. Weekly meal consumption. All safety devices in place and working condition. ADL's toileting transferring and meals minimal asst. tolerating PO meds, fluids, and meals. Working with OT/pt towards goals call light within reach. Continue to monitor

So is there anything I missed or can omit??

Thx

When addressing medications in my weekly summaries I will usually state "no adverse reactions to current medication regimen noted" if this is true, I always speak on use of PRN medications especially if they are behavior modifying medications as well as their response to them, if a new medication has been started since the previous weekly summary I will address it and also if they are on ABTs or recently have been I would address the medication and what it is treating. If I speak about the use of PRN medications that modify behavior I always chart what non-pharmacological interventions have been attempted first.