HELP! LTC clarification about charting and assessment

The interviewer is not blowing smoke up your butt about who you have to chart on. We typically chart on new admissions Q shift x 3 days, Q shift for anyone on antibiotics, and then there's special things like g-tubes, trachs, changes in condition, falls etc. We generally have more Medicaid residents than those on Medicare, so that sounds right too. Medicaid residents are more likely to be short-term, sub-acute rehab types, so it's a good idea to chart on them. Some of the most important documentation in our building though, is what the GNAs are responsible for: ADLs, BMs, continence, meal consumption, fluids offered.

Where I work, we have to chart on acute care resdents. Our acute care consists of those on antibiotics until complete unless the Dr requests new labs. If so, then we chart until labs return showing no evidence of infection remains. Other acute situations are falls x 72°, new meds to ensure no a/r x 72°, any changes in ADL and mental status, med refusal, appts in and out of facility as well as LOA, and those on contact precaution. If documenting on new meds and tx orders for first time order the nurses note has to mirror that of the original Dr order. Also, MDS charting is a must. CYOA... cover your own *$!#... hope this helps.

Charting varies.

Sometimes you just have a run of everything that needs to be charted on. And those shifts are horrendous with the quantity of charting required. You could be charting on 3/4 of the unit's pt population, eso with all the examples as provided by PPs.

But then it drops off to a more reasonable number. Like the ABTs end and the falls/incidents are finished. Some discharges home or pts in the hospital decreases the number also.

To me, it always seemed like there would be an increase of admissions on the weekends and right before a holiday (the hospitals like to clean out those times). So charting would creep up again.

Depending on your facility's practices you might have periodic charting of summaries (psych or monthlies). There's really no simple answer to how much.

The optimal approach to charting is to do what you can do early and then to chart it as quickly as possible. You cannot chart in advance for the whole shift (and I know there are nurses who wrongly do so). If you can close out your chart early, then good for you. I learned NOT to put off anything "for later" because when later came around, so did a fall, a diabetic bottoming out and a fire drill al at the same time!

Not all LTC places are bad, just like some hosptals are better than others. ' Horror stories' outnumber positive stories as negatives will most likely be reported more freq than positives.

If you're interested, give LTC a chance.