Hints for med passes and documentation?

dekatn · Aug 19, 2005

What exactly do you have to chart daily, I'm not familiar with the term hot chart. I do three med passes daily, a lot of the info is printed out on the MAR, so that as I am giving meds I can automatically write down what is needed. Give me more info, maybe I can help.

dinkymouse · Aug 19, 2005

Hot charts are pts that need daily documentation, such as things like infection, g-tubes, edema, skin problems, behaviors etc. We have separate forms to fill out daily for those people. Weekly we have separate forms we have to fill out for patients on coumadin, oxygen, weights, constipation, hydration, infections, their adaptive aids, w/c's, mobility etc. I have patients that I need to fill out 4-5 of these forms and a lot of it is redundant like vitals, weights, diet, edema, skin condition are on each one of these forms. There is no dietary report for our charting, we have to go to the kitchen and get their intake and outtake every week. The patients on oxygen we have to take their daily sats and breathing ease. The same things that are on the forms. Lung sounds are on the coumading, oxygen, infection and edema forms. Yes you can copy these on all the forms but I think it is a waste of time when you have 20-30 pts that need these filled out weekly. Many nurses just make up the data and file them. I won't do this but I am sure tempted sometimes. It can take up an entire shift doing these and when you are charge for all the patients you have a lot of other things to do. :angryfire They are supposed to be staggered over 3 days but if one day leaves it, the next day is supposed to do it. The coumadin, oxygen, edema and skin are all due on Tues., Hydration on Wedensday and constipation on Thursday. Many pts are on weekly b/p's and weights. The aides can get the weights but only nurses can do the b/p's. Blood sugars and insulin are on our MARS, we put the daily o2 sats in the tx book. There are separate forms for the weekly b/p's and weights. Different forms for the monthly vitals. The lists of these patients haven't been updated in months. Some of the people on these lists have been dead for months. Also any idea's on report sheets. No one dates when things have happened so it may not even be pertinent and you can't tell if labs have been done. I found out Wed. that a patient had been having diarrhea for over a week but no one had charted it, it was a word of mouth things. No one had given her the lomitil that she had ordered either.

dekatn · Aug 19, 2005

O.K., I'm gonna try this. We don't use all those forms. We have behavior form on the MAR, so on last med pass that day, I document how many episodes and what they were, there is a place for interventions, with a number system down the L side of page for us to use. This is only for pt. that are on some type of psychotropic med, not on everybody. This does require at times documenting in chart if behavior is abnormal for pt. Other than that it is only documented on weekly note.

Skin integrity or any problems is documented on the tx book. We have a tx. nurse that deals with all skin problems. This includes edema. When the tx. nurse isn't available it is our responsibility to follow up. We work together to moniter and manage skin integrity, edema.

Our I &O's are monitered by CNA's and entered into computer by them, which we can print out when needed. As are BM's, if one of our pt. hasn't had a bm over a 9 shift period, the computer will let us know. ( At the beginning of each shift, we print out a "bm list" which shows which pt. hasn't had bm).

CNA's also enter what percentage a pt. eats of each meal.

G-tube care and monitering is entered on MAR, this includes amount of flush, how often to flush, feeding, tubing is changed q 24 h on 11-7 with a place on MAR for nurse to initial.

Monitering for pt. on coumadin therapy is also on MAR, we initial each shift.

We have a calendar that we use, our ADON, set this up for us, all pt. are divided among all three shifts to chart on, this is for monthly charting.

Daily charting is also divided between shifts for all pt., we do have a few that require charting on q shift, but not that many and it doesn't usually last that long.

Mobility and adaptive aids are usually charted on monthly, unless they are recieving PT, then it is daily, but then again, this is divided among shift.

We do have a VS and wt sheet that we use, CNA's obtain VS, our restorative CNA's obtain wts.

O2 and sat's are also on MAR with place for us to initial and fill in sat results.

When we have a pt. on ABT for infection, we have printed on MAR, moniter for SE etc: with place for each shift to initial that this is being monitered. If there is something abnormal of course it would be charted and M.D. contacted.

The only daily charting is usually Medicare and if there is something unusual or abnormal going on with a pt. Wts are kept in "weight book" and moniter by ADON, VS are kept in VS book, it's just a plain three ring notebook with dividers A-Z, each pt. has a page in this book, filed by last name in alphabetical order. Same for wt book.

I don't know if any of this is helping or making things worse. It's hard to write down exactly how we do everything, but if you have any specific questions let me know. Maybe together we can figure out an easier way to do things. You are welcome to pm me.

Hairstylingnurse · Sep 10, 2005

Great advice, does anyone have anymore they could offer??????

O.K., I'm gonna try this. We don't use all those forms. We have behavior form on the MAR, so on last med pass that day, I document how many episodes and what they were, there is a place for interventions, with a number system down the L side of page for us to use. This is only for pt. that are on some type of psychotropic med, not on everybody. This does require at times documenting in chart if behavior is abnormal for pt. Other than that it is only documented on weekly note.
Skin integrity or any problems is documented on the tx book. We have a tx. nurse that deals with all skin problems. This includes edema. When the tx. nurse isn't available it is our responsibility to follow up. We work together to moniter and manage skin integrity, edema.
Our I &O's are monitered by CNA's and entered into computer by them, which we can print out when needed. As are BM's, if one of our pt. hasn't had a bm over a 9 shift period, the computer will let us know. ( At the beginning of each shift, we print out a "bm list" which shows which pt. hasn't had bm).
CNA's also enter what percentage a pt. eats of each meal.
G-tube care and monitering is entered on MAR, this includes amount of flush, how often to flush, feeding, tubing is changed q 24 h on 11-7 with a place on MAR for nurse to initial.
Monitering for pt. on coumadin therapy is also on MAR, we initial each shift.
We have a calendar that we use, our ADON, set this up for us, all pt. are divided among all three shifts to chart on, this is for monthly charting.
Daily charting is also divided between shifts for all pt., we do have a few that require charting on q shift, but not that many and it doesn't usually last that long.
Mobility and adaptive aids are usually charted on monthly, unless they are recieving PT, then it is daily, but then again, this is divided among shift.
We do have a VS and wt sheet that we use, CNA's obtain VS, our restorative CNA's obtain wts.
O2 and sat's are also on MAR with place for us to initial and fill in sat results.
When we have a pt. on ABT for infection, we have printed on MAR, moniter for SE etc: with place for each shift to initial that this is being monitered. If there is something abnormal of course it would be charted and M.D. contacted.
The only daily charting is usually Medicare and if there is something unusual or abnormal going on with a pt. Wts are kept in "weight book" and moniter by ADON, VS are kept in VS book, it's just a plain three ring notebook with dividers A-Z, each pt. has a page in this book, filed by last name in alphabetical order. Same for wt book.
I don't know if any of this is helping or making things worse. It's hard to write down exactly how we do everything, but if you have any specific questions let me know. Maybe together we can figure out an easier way to do things. You are welcome to pm me.