How to read&document on pt charts effectively? + how to transcribe physician orders?

pinkiepinkPN · Nov 24, 2013

Hi fellow nurses and anyone reading this! Today I started my first training day is an LVN at a skilled nursing facility. It was a long day and I'm still having trouble piecing all the pieces together. As the title states I am having trouble understanding the overwhelming amount of paperwork in the patients' charts. Is there a trick to deciphering what information goes where? Pt. change in condition, new physician orders (where to transcribe), nurses notes. And is there a specific guideline as to how to chart effectively and accurately? Thank you in advanced! Any help is appreciated :)[/quote']
Oh, I could SO have written this. I KNOW. Trust me. I just started my first job as an LPN in a LTC...Monday will be my sixth "training" (if you could call it that) shift and the paperwork is making my head spin. Something I plan to do this week is write down EVERY paper I see my preceptor filling out and keep it as a permanent list...where it comes from, when I use it, what needs to go on it.
Also, and this was something used to do during clinicals, I'm making a simple calendar page that has 4 sections on it- 6 to 9, 9 to 12, 12 to 3, and 3 to 6. I'll work with my preceptor to make a note in each section of what tasks other than med passes should be done in what time frame, ESPECIALLY tasks involving all this dreaded paperwork!
Good luck to you! New nurse power!

SquishyRN, BSN, RN · Nov 26, 2013

Here is an older thread where TheCommuter has a step by step of carrying out an order: https://allnurses.com/geriatric-nurses-ltc/ltc-617067.html

As for charting, chart specifically to the issue you are addressing. Include a brief general description of the resident, but otherwise focus on the reason you are charting. For example, if you are charting because they have a UTI, you generally don't need "pupils equal and responsive to light, respirations even and unlabored, skin warm and dry to touch with fair turgor, extremity strength equal..." Etc, etc. Some people say only chart the abnormals, but that's wrong. Chart whatever is relevant to what you're charting about. For example, having clear, yellow urine is normal, but that information is relevant for a UTI. Having clear, yellow urine, however, is not generally relevant for PNA, so for PNA you should include respiration quality and O2s sat, which would be unnecessary for a UTI.

Here is an example:

Resident alert, verbally responsive, oriented X4, and able to communicate needs. No signs of acute distress. Denies pain or discomfort. V/S: ____________. Continues on PO antibiotic treatment for UTI. No adverse side effects noted. No diarrhea, N/V, rashes, or fever noted. Urine clear and yellow with no foul odor or hematuria. No complaints of dysuria. Oral fluids encouraged and accepted. Proper pericare instructions reinforced with resident. Resident verbalizes understanding. Needs anticipated and met. Will continue to monitor.

Notice I started with a brief, general description of the patient and vital signs. Always include pain as it is considered a vital sign. Next I included the reason I am charting (ATB for UTI) and the reaction to the ATB. Then I addressed observations relating to the UTI. Then I addressed specific interventions and ended with generalized interventions. Another example:

Resident bedridden, nonverbal, and unable to communicate needs. Opens eyes spontaneously and is responsive to verbal and tactile stimuli. No signs of acute distress. No signs of pain or discomfort. No restlessness, moaning, or facial grimace noted. V/S: ____________. Continues on IV antibiotic treatment for PNA. No adverse side effects noted. No diarrhea, N/V, wheezing, or rashes noted. IV site to L forearm clear with no redness, swelling, warmth, or discharge. Resident noted to have occasional productive cough with clear sputum. Respirations even and unlabored. Temperature of 100.2F and O2 sat of 95% on 2L via NC noted. Cooling measures implemented. Breathing Tx administered as ordered and tolerated well. Fluids flushed via GT as ordered and tolerated well. Needs anticipated and met. Will continue to monitor.

Again, same general format but tailored to PNA instead of UTI. Even though you are an LVN and are not the one administering the IV med, you are still the one monitoring and charting about the patient's condition and response to treatment.

It's been awhile since I've worked LTC, so I'm a little rusty. Hopefully, someone else can add on or clarify anything I've forgotten. But it's pretty formulaic once you're used to it.