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Discussion

Guidelines for required charting in LTC..

Is there anywhere where I can find what the guidelines are for monitoring/charting temporary problems in LTC? I feel like the facility where I work is lacking when it comes to monitoring and charting on any temporary problems ie: change of condition, infections, med changes, psycho-social changes (grieving/death of a room mate or loved one)..

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    We chart on bath day (skin assessment, weight, eating over the past week) New orders, contact with MD, dressing change, change in condition, q shift after every hospitalization or fall. We use a reminder sheet clipped to the chart with an area to sign off on.

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