So the facility I work for is now requiring that night shift finish our documentation by midnight bc if we don't "it looks like we're not documenting". This irritates the crap out if me!!
#1 We can't chart until we've done our treatments, so how are we supposed to complete a whole shift's worth of work in less than 6 hours? Our HS Med pass is not huge but it's heavy.
#2 Why do we have to finish our charting by midnight when day shift often stays after their shift has ended to chart? I realize that day shift is more hectic, but come on!
#3 Residents who we have to chart behaviors on may not have behaviors before midnight but often will after midnight.
Can you make it a late entry - ie "Late entry for date/time - assessment done showed...". That should satisfy the requirements and surveyors will clearly see that documentation is being done within your shift in my opinion.
Can you make it a late entry - ie "Late entry for date/time - assessment done showed...". That should satisfy the requirements and surveyors will clearly see that documentation is being done within your shift in my opinion.
from then on there will be charting for that day from
the previous noc shift
btw, how many treatments are you doing after midnoc?
I don't do any after midnight now. I have to have them done before I do my documentation. Right now I only have about 5 treatments so it's not too bad.
Our facility allows us to start a note and save it as a draft. That way I can start a note at 2230 but finish it a 0400 but the time I started it stays at 2230. I am not sure if your system will allow for this, but it is sure a good way get things started and finish it at a later time.
Our facility allows us to start a note and save it as a draft. That way I can start a note at 2230 but finish it a 0400 but the time I started it stays at 2230. I am not sure if your system will allow for this, but it is sure a good way get things started and finish it at a later time.
This is a good idea and I'm not sure if we can do this or not. I will ask tho!
At our facility the NOC shift is required to chart on all the Medicare residents + any additional "alert" charting for LTC residents on ABX, etc., each shift is required to do complete charting. There are 2 nurses on my unit during the day (34 residents) and then 1 NOC nurse. As long as the charting is done on your specific shift, they don't complain about charting after midnight. Although if you still have charting after the day shift has started, you have to indicate you are "late charting" for the NOC shift. Most of the time we're passing NOC medications to 25-30 of the residents, so you're passing meds almost up to midnight. You're also interrupted constantly by call lights that the CNAs are unable to answer. A lot of new nurses who have never worked in SNF/LTC are overwhelmed by the amount of work involved. Many times we're charting on 20-25 medicare residents + 5 "alert" charted residents.
Our facility allows us to start a note and save it as a draft. That way I can start a note at 2230 but finish it a 0400 but the time I started it stays at 2230. I am not sure if your system will allow for this, but it is sure a good way get things started and finish it at a later time.
Reeks of fraud- meaning, your place lets it make it appear any required skilled documention was completed on a certain date before midnight, even though it was completed on the following date. If that's the case, your place allows you to start a note '2-5-2013 @2030', without actually doing any documentation, and allows you to complete the actual documention on the NEXT day to justify a skilled service, from the prior day? Aside from that, think about this:
-You, the nurse, had to leave suddenly at 0100 for a family emergency. Unfinished notes left laying around.
-The patient expires at 0015, and yet you already started (and 'saved') a note at 2030- what do you say at 0400, the next day, to make it appear that you are documenting as events unfolded? A summary note of the shift? When exactly, on what date, do you claim the patient expired? On 2-5-2013, when your note started, or on 2-6-2013? Do you then change the original date of your 'saved' note?
I bet any place that would allow this nonsense, also allows its nurses to presign meds or txs as completed on 2-5-2013 that are required to be done on 2-5-2013, even though they are not done until 2-6-2013.
Better idea- why can't you end and sign your note at 2030 if you can't complete a full note, then start a new note next day at 0400? Reeks of fraud.
I agree with some posters in suggesting you "back-date" your charting/assessment. Our facility also allows you to write a note, and then link a follow-up note to the original note. That way, you can add things that happen later in your shift and point to things that happened in the beginning as well.
Could you pick one night to do 2 assessments? One before midnight and one after midnight? Then the next night would already have charting on that day and you could have the rest of the shift to get your assessment and charting done?
Well of course you would write a note with your assessment at the beginning of your shift and a second note later for any condition changes. You can't chart at 2200 for the whole night. What I was speaking of was a note started at 2230 for your assessment but it wouldn't include a condition change at 0400....that would be fraud. Management can't dictate you to chart the whole night prior to MN.....however I can see them wanting assessments completed and charted prior to MN.
systoly
1,756 Posts
you only have to do it one time
from then on there will be charting for that day from
the previous noc shift
btw, how many treatments are you doing after midnoc?