documentation

blondie · Jan 8, 2002

Honestly, I think my facility could benefit by putting scheduled tests and appointments on computer. Making changes would be so much easier, and it would nice to have everything in one tidy data base.

Not really seeing that in the near future, one thing I've done is not to repeat the entire MD order in the nurses notes. I don't see the point of doing this when the original order is kept right there in the chart. Instead of "NOR Levaquin 250 mg po qd x 10 days," I might write "NOR Levaquin."

I'm still learning, but my main goal is to reduce duplication of effort.

CoachCathy · Jan 13, 2002

It really depends on the part of the documentation that you want to focus on. I do QA in a facility that is part of a 43 facility corporation. It always amazes me to go to a sister facility and see how differently they are doing things. The regs give you a minimum, your Board of Nursing gives you a minimum and your facility will give you a minimum. One of the biggest tasks that I undertook when I took this position in this building (where they were averaging twenty deficiencies per year !?!?) was to stream line the MARs. It took FOREVER, but the time that we are now saving the charge nurses was well worth it - things like residents having several meds ordered "QD", but having two different nurses at three different times administer the meds. We looked at each individual patient and tried to decrease the number of times that we had to enter the room with medications. (As long as timing wasn't an issue, etc., etc). With scheduled tests and appointments (I also throw labs into this), I keep a file box with a card for each patient. I update the card whenever the resident has a new order. I divide the cards by month and update daily. It seems to work for me, and has cut down on my paperwork. Really, truly - the most important documentation is the MAR and the nurses notes. Depending on where you live, nothing else may be admitted into court. If you have facility forms that you are double documenting something (I saw a facility that charted accu-checks in five different locations), go back and see if this was a deficiency somewhere. Administrators tend to do a knee-jerk reaction when they get cited for something and don't always look at the big picture. (Like implementing forms for EVERYBODY, when only one or two nurses are at fault). Good luck!!