any facilty overdocument???HOW FRUSTRATING

Bird2 · Nov 18, 2005

Unfortunately LTC's are known for over regulation and facilities pay the price for noncompliance. The regs clearly state that an injury of unknown orgin can be considered abuse. That is why they are getting statements from so many people. When filling out an incident report for a bruise, skin tear etc never put "origin unknown". Just state the facts. It is helpful if you can document something like "3 cm skin tear to right forearm. Blood noted on siderail." Try to give good details so that your QA person does not have to run around getting statements. Why would you have to do head to toes on 49 residents??

SFCardiacRN · Nov 18, 2005

I have found "overdocumentation" to be a wonderful thing when doing chart review. After a year or more has passed and an unexpected query has been posed, only the minimally documented charts pose problems. Charting those barely obtrusive pre-admission skin breaks can save your bacon when doing QI on infections or hospital care. Don't forget the bruises either.

organichombre, ADN, BSN, MSN, LPN, RN · Nov 18, 2005

Documentation is necessary to protect the pt and yourself. As the other replies state, a good assessment by the admission nurse makes it much easier for those who follow.

dinkymouse · Nov 30, 2005

I agree that a good assessment is necessary and charting must be detailed. What I find so awful is that many of our forms have the same redundent questions. On a typical 3-11 shift as the only nurse I estimated that I signed my name or initials over 500 times and that didn't include my nurses notes. It seems that all these initials are more important than my spending time assessing for skin breakdown.

Bird2 · Nov 30, 2005

I agree that a good assessment is necessary and charting must be detailed. What I find so awful is that many of our forms have the same redundent questions. On a typical 3-11 shift as the only nurse I estimated that I signed my name or initials over 500 times and that didn't include my nurses notes. It seems that all these initials are more important than my spending time assessing for skin breakdown.

Sometimes LTC's in a panic create forms to satisfy DPH requirements. I have worked the floor and in management so I truly believe that the best information is obtained by the floor nurses. The management team may not be aware of how redundant your documentation is. Maybe the forms can be condensed and consolidated. Take your suggestions to management and with the knowledge they have with Sate and Federal compliance your entire team may be able to fix your problem. Though you should trial each new form on one unit only in order to work the kinks out of them instead of just implementing them. This may also create a new, improved working relationship between the floor nurses and the nurse managers.

dian57 · Dec 1, 2005

I agree with Bird2. As a floor nurse, duplicate documentation made me crazy. As a Clinical Care Coordinator I recognized the danger of duplication--the more places the same information was written, the greater the chance of a discrepancy in the patient record. And you just KNOW the state will find that discrepancy and grill you on it.

Now, as DON, I'm able to do something about it. We've combined a lot of forms (I&O and meal monitoring, for example) so we're only writing things once. Weekly psych notes are referenced in the chart. The BP taken for 9 am Cozaar is enough. The 9 am Norvasc and Diovan have lines drawn through the BP boxes. Psych vitals for residents on antihypertensives have SEE MAR on the BP line.We're currently working on reducing the Admission Assessment forms from 12 (yes, 12) pages as a lot of the information is found elsewhere in the record.

Unfortunately, as long as a injury of unknown origin is discovered, an investigation must be done to reasonably rule out abuse. I don't see that changing anytime soon. At every nurses meeting, I ask the staff about duplicate documentation and for their suggestions for streamlining the paperwork to give them more time with the residents.

tlrochelpn · Dec 7, 2005

In the LTC i work at we over document big time, ever little bruise and scratch. We even do total new admissions if a resident changes level of care, for ex: rcf to icf or skilled to icf, we have to redo everything all orders, assessments everything.