Nursing Home Charting

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  2. I was at the Nursing Home(im a student), and I noticed that some Nurses were having trouble finding stuff to chart about concerning the residents.I work as a CNA at night and would like to know what tips anyone can offer on "what to chart" especially on residents who are fine and just sleeping all night.Charting tips appreciated.:chuckle
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    Joined: Jun '03; Posts: 6


  4. by   kids
    Charting on NH patients is usually for a specific reason and the note should reflect that.
    I would suggest that you review your facilitys documentation policy as to specifics as the requirements can vary greatly from facility to facility.
  5. by   RUNEMASTER
  6. by   Sue RN GNC(C)
    In our facility, we use focus charting - focus -data, action, response and plan. We chart relative to the abnormal - so it is important to establish a good baseline for the residents own "norms".. we are required to chart at least monthly on each resident, each shift for 3 days when they are a new admit. You are always safest by over charting, rather than under charting - so if it is "abnormal" to you, then chart it! a good example is sleep.. it is "normal" for a person to sleep at night, so "slept well" is pretty redundant.. now, if you have a resident who NEVER sleeps at night, then a night they do sleep would by "abnormal" for them.. so you would chart that.
    We currently have a huge problem with charting.. our nurses will add the anecdotal notes to the Kardex, but then neglect to chart that info in the resident's chart..the Kardex is not a formal piece of the residents chart and is used only as a communication tool.

    Good luck, and trust your instincts.. you can't go wrong if you document accurately.
  7. by   RUNEMASTER
    Actually, im not a CNA at all Im really a Nurse,but only for a while longer.But i really appreciate your response. Im not one that really likes Nursing as I do not believe in the American medical drug industry at all.But i wanted to get feedback from other Nurses to see what they would respond.I appreciate your straight forward approach.Thanks.Ive been a Nurse for about two years and I hate it.But i still wanted to learn what others know.Thanks and good luck.Im moving to Europe next year retiring early.No more Nursing for me.Peace and good fortune.Cya.
  8. by   itsme
    You should update your profile- it says nursing student and that nursing is your interest! If you are a nurse, be p roud, and enjoy Europe!
  9. by   WeSignificants
    Sorry to hear you didn't like nursing and are leaving.