Charting issues?

[sanchezlpn]

Question, I work in a facility where it is assisted living, the residents have dementia though...so we must assist and most cannot tell you for sure information if you need it, such as when did you last bath, when did you use the bathroom, etc., they are not able to tell us this information.

My question is this....why wouldn't the facility have all shifts, all cna's chart b/m's etc. when this is important information for the nurse, espectially when they are taking meds? I have come into an issue where this is not being done accuratley and just recently a resident complained of hurting in her stomach (we think), and I asked my supervisor about charting, she said we don't do this because they the residents should be able to tell us this information....so.....how does a nurse treat for the right condition, bowel obstruction, impaction, or plain stomach ache ?

Am I really asking too much? I need some input on this....please LPN's out there give me some infor on how to handle this appropriatley....

nursing gal

[jimthorp]

Question, I work in a facility where it is assisted living, the residents have dementia though...so we must assist and most cannot tell you for sure information if you need it, such as when did you last bath, when did you use the bathroom, etc., they are not able to tell us this information.

My question is this....why wouldn't the facility have all shifts, all cna's chart b/m's etc. when this is important information for the nurse, espectially when they are taking meds? I have come into an issue where this is not being done accuratley and just recently a resident complained of hurting in her stomach (we think), and I asked my supervisor about charting, she said we don't do this because they the residents should be able to tell us this information....so.....how does a nurse treat for the right condition, bowel obstruction, impaction, or plain stomach ache ?

Am I really asking too much? I need some input on this....please LPN's out there give me some infor on how to handle this appropriatley....

nursing gal

If it's not company policy for the CNA's to chart b/m's etc and the patient is not a good historian, the only thing I can say is it won't hurt to give a resident some MOM unless they have contraindications for MOM or no order for it. You could also take the person to the bathroom and check.

[systoly]

Sounds like a placement issue to me.