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HELP! I need a new report/brain sheet.

by svicente0520 svicente0520 (New) New

I'm a new nurse (6 months as LPN and one as RN) I work as a RN at a LTC/Rehab. I love my job and taking care of the elderly. I know it's not for everyone. I am struggling with keeping up on the documentation. My supervisors expect the best documentation possible. Which I do (mind you we have to do narrative documentation). I at times have to stay 3-4 hours over my shift to finish everything. Since most residents are on Medicare the documentation required is to be very particular so that we may get paid. Some days I have to document of 15-17 residents. That's not including the now required COVID documentation, calling families, putting in orders, my actual job of passing meds, wound care,  and IV abx. Lord forbid there be a fall. The paperwork is immeasurable. I feel so overwhelmed. I do love what I do but I need a way to finish all my task to go home on time. I mean 16 hours days are really long. If you could please send me some templates or anything, I would truly be grateful. 


Specializes in LTC. Has 10 years experience.

Here is a cheat sheet I created for myself to use. Feel free to tweak it to fit your needs.  Don't be too hard on yourself, getting a routine takes time. Talk with your supervisors and come up with a plan together.  Medicare charting is daily charting so see if you can divide it up on other shifts. And yes it is very particular but keep it short and to the point.  Chart only on what is requested.  Are they meeting goals? Eating? Pain controlled? 

Here is an example: 

Skilled charting: Orthopedic surgery (except major joint replacement or spinal surgery): Primary diagnosis: PSF of T4-L3 with Osteotomy. The resident had PRN pain med x1 this shift which was effective. The resident was in bed this shift due to mobility restrictions. The skin has no signs of breakdown and the incision looks good and well approximated. There are no concerns with appetite or elimination. The resident is participating in therapy and doing bedside ROM progressing toward her goals. Nursing will continue to monitor.

The more you do this, the better you get. Don't give up. It takes time to get your routine down. 


Updated cheat sheet NOCS.docx