Writing a sufficient nurses note

Nurses General Nursing

Published

Started new job in LTC Skilled Unit...and I am having trouble with my nurses notes....have not had to do nurses notes for awhile becuse of working in physician office....any advice from seasoned nurses on writing nurses notes that are sufficient for medicare/insurance purposes as well as for documenting effectively on my residents. Thanks!

Specializes in Pediatrics and geriatrics.

When I worked in a LTC skilled unit, we would do documentation if there were wounds, incisions, and etc. We would also document on how the resident was able to do ADLS without assist, how does the resident ambulate? Is the resident totally dependent on staff for all ADLS? Is the resident continent? Does the resident have a trach? Document trach care and if suctioning was needed. Chart when the trach or inner canula is changed. Is there a wound vac invoved in the care of the patient? Describe the drainage and the wound characteristics.

I now work with kids and dont have to deal with Medicare charting, so these are the biggies that I remember. Hope it helps.

Specializes in Med/Surg, Rehab.

Your MDS nurse is a great resource for this question! You'll want to make sure to mention any assessments about why they're in the facility. Like, for a post-op TKA, you'll write if they use the CPM, any ambulating they're doing, range of motion, pain control, bed mobility, how the wound looks/dressings, etc. For every patient, you want to write about pain control, how their PO intake is, any weight loss/gains, medication changes and any new orders.

Specializes in Med/Surg, Rehab.

Basically you want another nurse to be able to go back and have a clear picture of what went on with your resident on that particular day. Did they start or continue on any antibiotics? Any temperature or abnormal vitals? I chart different things on each of my residents and it took me about 6 months to start writing good ones.

Great advice so far!!! Really hopefull that a few months from now I can get a good grasp of things and be a great LTC nurse!! I think I've found my "niche"!

At more than one facility where I worked, there were inservices held on Medicare charting and we were given handouts with specifics. Look around your facility and ask the staff development person or the DON for a copy of any such "cheat" sheet used at your facility.

+ Add a Comment