From SNF to Hospital Setting

[flamengo]

Hello. I am wound care nurse for the past 5 years and have been in a Long Term Care/Subacute setting. I recently got hired as wound care nurse educator at a hsopital setting. I am having diffculty with the new fast paced environment that I am in now. One day the patient is in, the next day either they were transferred to another unit or have been discharged. I do a lot of chart audits and I am having trouble with how the nurses do their documentations. I ahve educated them proper documentation and risk for not doing so but doesn't seem to work. Thank you.

[woundnurse4u]

I started my nursing career in LTC many years ago so I understand where you are coming from. Yes, you need to expect rapid discharges and musical beds. Just as you are being challenged by this, so are the nurses.

When you say that you are having trouble as to how the nurses are documenting, can you specify? I will make the assumption that the nurses are charting electronically and not on paper. Your char audits should identify the most fundamental problems.

What does your policy on wound documentation look like? Is it an easy to follow policy? Does it need to be tweaked or even re-written for end-users? If your audits demonstrate the deficits, match those deficits to what is in the policy or identify what is missing from the policy. What is the basic expectation that they are having trouble with?

If everything is well-established by policy/procedure, simple to follow, and the nurses still won't get on board, have you asked them why they are having such problems? Have you mentioned how proper documentation might make their jobs much easier in the long run (ie everyone is doing it the same way so it is easier to follow the care and share information)?

At the end of the day, you have pointed out the risk aspects. Everything is peachy until you have to defend your own documentation in a deposition. If the documentation deficits are enough, it is hard to defend everyone's care of the patient. Is your Risk Management Team aware of the documentation issue? Is your Nurse Management Team aware of the issue as well?