New grad LTC

amoLucia · Jun 19, 2012

You might want to check with your Inservice/Staff Developement person who probably has samples/handouts to help you. I know psych charting and notes for skilled/rehab nursing are troublesome for many. Charting for MDS reimbursement is found in your skilled charting so you'll need to focus there with specific detailed entries. This is a BIGGIE.

Continuity of care needs to be seen in your charting. By this I mean if it was an issue on the prior shift, you most likely willl need to document on it on your shift, esp if the previous nurse forgot to chart (like if a GTube was reinserted, you should chart something). There are ways to do it and to do 'late entries'. Admissions, significant changes of status, wound appearance, MD contacts, family communication, ABT, falls, incidents, teaching, discharges, etc etc etc all require charting but your facility may have specific forms to use and your policy & procedure manual should guide you. Again, your SD nurse can help.

Some tips --- get in the habit of reading 2-3 entries ahead of your entry. It will give you areas to focus on and also you'll see who charts well so you can learn from them. Please avoid the 'dear diary' type of charting - repetitive non-specific charting just for the sake of charting. Don't waste your time! Be careful of 'left' and 'right' entries (so many mistakes are made). And be sure your note MATCHES the MD order (like if O2 at 2 lpm matches the O2 at 2 lpm order even if the nurse ahead wrote 3 lpm!). These are 2 reasons I like to read the previous notes!

Some NO NOs --- don't ever be negative, judgemental or point accusingly at some other staff nurse, MD, dept head, etc. The progress note should reflect patient care not problems with staff. And don't put the facility in a bad light - not the place to do it!!! Negativity will come back and bite you in the butt! And please, please, please never, ever leave space for someone!!! People are STILL doing it. Let them do a 'late entry' if they must. If your pt goes bad, they could write something in that blank space that leaves you at fault. DON'T DO IT!!! Be careful of abbreviations (don't make anything up). I tend to just shorten words. Penmanship is crucial - I do know of surveys that have have commented on problematic handwriting.

I'm not a DON/ADON, but I have been supervisor and Staff Developement (can't you tell I like to teach). I could go on & on because I have been responsible for staff documentation. Staff Dev probably has examples that you can just fill in the blank. There's not enough room on this site to be specifically specific. Good charting will become easier and quicker as time goes on. And it's your legal defense. Good luck.