documentation guidelines

Tim-GNP · Dec 20, 2002

There is a web site you might be very interested in.... it is the home page of the Nursing Assessment Coordinators. I think it is: http://www.aanac.org

They have links to various forms you can download, and give information on the latest RNAC news.

Good luck with your new job

ktwlpn, LPN · Jan 5, 2003

Any place to get this same type of info for free? Our DON is documentation happy and has us doing things that other ltc's in our area don't-partly because as a county home we are held to different standards then the area private homes.The inspectors would deny it but they go over our institution with a fine tooth comb but when they are greeted by the therapy dog and a tray of danish at the pretty private place I left last year they tend to put on their rose colored glasses.Ironically my county run facility is the best staffed in this area(great bennies and pay rates) We are still doing monthly summaries.We do skin assessments weekly and wound measurements weekly in 2 separate books but we must also do a nurse's note detailing the info we have just documented on the wound measurement sheet......We have a great restorative program and the goals are set in team but we have to write a note on each resident every 2 weeks stating their program goals and level of participation even though the restorative cna's document daily....We document q shift x 7 days on new admits and hospital returns-q shift on med a's....and follow through for 24 hours any incident on report.The last facility I left was never cited (in the 2 and a half yrs I was there)for not dating opened bottles and vials....We are always checked for this one....Seems like we are doing alot of redundant documentation-why should we write the info out in more then one place?And these narrative summaries-what can you say that has not already been said a hundred times?