Charting a patients transfer status

[dschaible]

Hi Everyone,

I work in a Long Term Care Facility, my patient's order on his kardex says he is a two person assist. But when I went and ask my patient if they went to the bathroom he said he walked himself. So when i went to chart i charted he was independent because he toileted himself. i was told my my manager and therapy that i should have charted two person assist. But he wasnt, i didn't toilet him and he took himself.

i asked my educator and she agreed with me that i needed to chart what the patient did and to inform therapy and my supervisors that he may need re-evaluated

was that correct? or should i have charted what the order said?

Thanks

[AceOfHearts<3]

I would chart the patient moved unassisted and unwitnessed. In my opinion you don't know that the patient truly moves well enough to be labeled independent unless witnessed by approproate staff.

Many patients claim they are independent, but really need help to ensure they are safe.

edit: I'd also educate the patient on asking for help, document the education, assess the patient's ability with another person (to cover your bases and follow the order), then request updated PT/OT plan as needed.

[dschaible]

Ok, Thanks so much

[Ambersmom, BSN, RN]

Hi Everyone,

I work in a Long Term Care Facility, my patient's order on his kardex says he is a two person assist. But when I went and ask my patient if they went to the bathroom he said he walked himself. So when i went to chart i charted he was independent because he toileted himself. i was told my my manager and therapy that i should have charted two person assist. But he wasnt, i didn't toilet him and he took himself.

i asked my educator and she agreed with me that i needed to chart what the patient did and to inform therapy and my supervisors that he may need re-evaluated

was that correct? or should i have charted what the order said?

Thanks

I would never go off what the patient says, I probably would have charted that was able to ambulate with minimum assist (maybe he was having a good day?) then request PT to eval. Now if I had him often enough to observe him frequently and see how well he moved and toileted, I might change the charting to minimal assist, some places have a vested interest in charting patient requiring a higher level of care, or it could be that when he came in he was a higher level of care but has now regained strength to require a lower level of care.