Charting on Dementia/Alzheimer's

Specialties Geriatric

Published

Hi All Nurses,

I would really appreciate your guidance once again. Why would the previous nurse document (paper charting), alert and oriented times three on the Dementia/Alzheimer's clients?

They know their names, but, have to be repeatedly reminded where they are or how to get to the restroom throughout the day.

Any help you provide on how to write comprehensive, narrative nursing documentation on these Older Adult clients will be be treasured! Thank you so much.

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Specializes in Critical Care, Med-Surg, Psych, Geri, LTC, Tele,.

Perhaps the other nurse asked the pt her name, and she knew it. Perhaps she asked her what day it was and she knew the year, or knew the day of the week and perhaps the resident even could state the name of the city or the facility.

Some people with dementia go in and out of awareness of these things and perhaps the other nurse caught the resident at a good time.

I try to only chart based on my own observations. And if mine are completely different than other nurses, I make sure I can back up my claims.

Narrative charting is still hard for me. My facility hasn't told me exactly what they want included in daily charting and it seems every nurse does it differently and (it appears) some nurses who never leave the med room chart a full head to Toe assessment.

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Specializes in dementia/LTC.

I would mention to the manager just incase other nurses need a reminder on what A&Ox3 means, especially if you are seeing that written for pts you are pretty sure are not. What I started I asked a couple managers to look over my charting to see if I was documenting the way I should. With Ltc I chart only when there is an issue/change/follow up needed.

Keep it simple but cover all your bases.

An example on a fall follow up might look like:

Resident A&Ox1. VSS WNL, Neuro checks WNL and completed. denies pain, no s/s discomfort/distress. ROM WNL. Ambulating independently c FWW s issue, steady gait. Up for breakfast in DR, ate 100% 360cc. Refused lunch, snack offered at 1400 declined x3. Incontinent x2 this shift, check and change q2h implemented.

With dementia pts I find it important to not only write denied pain, but that I don't see any symptoms of pain because frequently they can't verbalize pain correctly or if not at all then of course you can't write 'denied pain'. Document reapproaches and alternatives that were attempted. If a res if having behaviors our np s and drs like to see more than "restless despite multiple interventions " they want Me to document all the interventions I used...toileting/position change, food/fluids, ambulation, music, massage, prn meds, 1:1 time, etc. They also dont care to see "anxious" without more description ex: pacing halls for 4 hrs, unable to sit to eat during meal time, looking for husband and unable to distract/comfort/redirect.

Hope that helps, each facility will be slightly different.

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Thank you so much vintagemother. Your reply makes me feel much more comfortable. It's what I observed about the client's behavior at that moment.

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I had a resident recently who is somewhat demented tell me her full name, the day of the week (maybe it was a lucky guess idk) and she knew she was in a medical facility of some kind...crazy huh?? I had to write aox3!

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Thanks kindly misstrinad,

Your advice is very helpful too. What I like most about your reply is I should give details to describe the anxiety, if observed.

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Specializes in Geriatrics.

If a patient with dementia goes in and out of being alert I usually put "able to recall name, time and place, periods of forgetfulness observed." Our facility likes us to put in quotes whatever the patient said so this could be the opportunity for you to chart subjective data to cover yourself.

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Specializes in Gerontology, Med surg, Home Health.

If the resident has dementia why chart their mental status? Do you chart A &O x 3 on every cognitively intact resident? I see nurses writing things just to write something.

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Specializes in dementia/LTC.
If the resident has dementia why chart their mental status? Do you chart A &O x 3 on every cognitively intact resident? I see nurses writing things just to write something.

Out of my 30 dementia pts I currently have 1 that could quality to be a&ox3 and several a&ox2. Most only to themselves, and the rest to none.

I don't chart it on most of my pts, because like you mentioned there is no need to. However on a fall f/u (the example I used) I do, if we were doing Neuro checks (in that case they either hit their head or it was unwittnessed ) I feel the need to check and document a&o status.

Hope that helps clarify how I chart with dementia pts.

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Thanks for all the great tips and for your guidance everyone! Your support means a lot to me, because, during nsg school, I was usually paired with the nurse who didn't want to teach or impart her/his knowledge.

This is my first time working with a solely geriatric population. As you all know, the human mind/ or level of awareness, is both fascinating and complicated. You can't help but wonder, in the future, will I be like my 107 year old client whose short-term and long-term memory is completely intact, or will I be like the 68 year old former college professor who has to be reoriented or reminded to take his medications daily.

*note - I rarely/almost never give meds, attendees at this senior center bring their meds from home

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