If the patient is skilled rather than custodial care you should chart something about the reason they are skilled e.g. for a hip replacement you would talk about the surgical site and the site care and whether or not they are working with P.T., the weight bearing status, the level of assist needed with ADL's etc.
Pre-nursing student here with a question...I have been told that as an RN you are too busy to see a patient and then chart, and then see a patient and then chart. My question to that was to ask how on earth you can even REMEMBER everything 3 or 4 patients later! Do you have a recorder you speak into or do you write it all down in a pocket notebook or what?
People write it all down after their memory banks start to fail them with age. I guess it is feasible to use a recorder if your facility doesn't ban them because of HIPAA issues.
I have been told to be very specific about PT/OT/Speech for skilled patients. Also, there are little handy medicare charting guideline books out there that a veteran nurse passed on to me...outlines each particular to include by condition/d(x)...very helpful if you can get your hands on one...
FLArn
503 Posts
If the patient is skilled rather than custodial care you should chart something about the reason they are skilled e.g. for a hip replacement you would talk about the surgical site and the site care and whether or not they are working with P.T., the weight bearing status, the level of assist needed with ADL's etc.