Nursing Home Charting

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I was at the Nursing Home(im a student), and I noticed that some Nurses were having trouble finding stuff to chart about concerning the residents.I work as a CNA at night and would like to know what tips anyone can offer on "what to chart" especially on residents who are fine and just sleeping all night.Charting tips appreciated.:chuckle

bg.bmp

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Charting on NH patients is usually for a specific reason and the note should reflect that.

I would suggest that you review your facilitys documentation policy as to specifics as the requirements can vary greatly from facility to facility.

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Thanks.

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In our facility, we use focus charting - focus -data, action, response and plan. We chart relative to the abnormal - so it is important to establish a good baseline for the residents own "norms".. we are required to chart at least monthly on each resident, each shift for 3 days when they are a new admit. You are always safest by over charting, rather than under charting - so if it is "abnormal" to you, then chart it! a good example is sleep.. it is "normal" for a person to sleep at night, so "slept well" is pretty redundant.. now, if you have a resident who NEVER sleeps at night, then a night they do sleep would by "abnormal" for them.. so you would chart that.

We currently have a huge problem with charting.. our nurses will add the anecdotal notes to the Kardex, but then neglect to chart that info in the resident's chart..the Kardex is not a formal piece of the residents chart and is used only as a communication tool.

Good luck, and trust your instincts.. you can't go wrong if you document accurately.

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Actually, im not a CNA at all Im really a Nurse,but only for a while longer.But i really appreciate your response. Im not one that really likes Nursing as I do not believe in the American medical drug industry at all.But i wanted to get feedback from other Nurses to see what they would respond.I appreciate your straight forward approach.Thanks.Ive been a Nurse for about two years and I hate it.But i still wanted to learn what others know.Thanks and good luck.Im moving to Europe next year retiring early.No more Nursing for me.Peace and good fortune.Cya.

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You should update your profile- it says nursing student and that nursing is your interest! If you are a nurse, be p roud, and enjoy Europe!

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Sorry to hear you didn't like nursing and are leaving.

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