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LTC Charting: A Beginner's Guide

Geriatric Article   (147,268 Views 60 Comments 1,413 Words)

TheCommuter has 10 years experience as a BSN, RN and works as a CRRN, now a case management RN.

21 Likes; 1 Follower; 228 Articles; 315,350 Visitors; 27,607 Posts

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Questions regularly arise regarding the topic of appropriate charting in LTC. Many nurses who are new to the realm of the nursing home setting are sometimes confused about what and how to document. Here is a list that barely scratches the surface of events and situations that warrant the need to write a nurses note in LTC. You are reading page 5 of LTC Charting: A Beginner's Guide. If you want to start from the beginning Go to First Page.

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At the facility that I work at we chart all of the aforementioned as well as weight increases/decreases of 5lbs or more. We also have to notify the MD and RP and chart that as well. We also chart any dietary changes or therapy orders ( new or d/c'd). And let's not forget meal completions and hydration notes. We also have to document at least three different methods of alternative resolution before we administer a PRN Narc along with the effectiveness after administration. We have to chart mood/behavior for 72 hours when any psych or depression med is started, decreased or increased. Thank goodness I type very fast!

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TheCommuter has 10 years experience as a BSN, RN and works as a CRRN, now a case management RN.

21 Likes; 1 Follower; 228 Articles; 315,350 Visitors; 27,607 Posts

Thank goodness I type very fast!
And thank goodness the LTC facility where you work seems to utilize electronic charting, or else all of this added documentation would take forever and a day...

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vintagemother works as a Nurse and Mom.

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And thank goodness the LTC facility where you work seems to utilize electronic charting, or else all of this added documentation would take forever and a day...

Yaaaaaassss!!! This! When my LTC facility moved to electronic charting of meds..... My life became much easier! I became so much faster at the super huge med pass!

Who would have thought my slowness was related to flipping through umpteen MAR pages in 2 binders!

And the check boxes to do assessments and inability to save a doc unless it was complete? ..... Priceless!!!

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Lol.you're right! We do use EMAR and PCC. Even so management still dictates that we have to do additional charting in our progress notes on what we charted in EMAR or PCC so that they can see it during their morning meetings. So even though we document VS for instance in EMAR we still have to include those signs in our alert charting via a progress note in PCC.

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Thorough information.Tomorrow would be my first day of work in SNF. Surely I would print this out and make this as my bible.:bookworm:Thank u.

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9,347 Visitors; 367 Posts

Happy that I came across this post. Will be printing it out for a reference when I start my first job later this month. Thanks commuter, great information for a new nurse.

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TheCommuter has 10 years experience as a BSN, RN and works as a CRRN, now a case management RN.

21 Likes; 1 Follower; 228 Articles; 315,350 Visitors; 27,607 Posts

Happy that I came across this post. Will be printing it out for a reference when I start my first job later this month. Thanks commuter, great information for a new nurse.
Thorough information.Tomorrow would be my first day of work in SNF. Surely I would print this out and make this as my bible.:bookworm:Thank u.
Both of you are very welcome. :)

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Glycerine82 has 3 years experience as a LPN and works as a Licensed Practical Nurse.

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Ty for this!! Started my first nursing job at a LTC facility and This clears a lot of stuff up for me. You rock!

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I'm considering going PRN at an LTC and this was very informative! Thank you!

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TheCommuter has 10 years experience as a BSN, RN and works as a CRRN, now a case management RN.

21 Likes; 1 Follower; 228 Articles; 315,350 Visitors; 27,607 Posts

Ty for this!! Started my first nursing job at a LTC facility and This clears a lot of stuff up for me. You rock!

I'm considering going PRN at an LTC and this was very informative! Thank you!
Both of you are welcome!

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Glycerine82 has 3 years experience as a LPN and works as a Licensed Practical Nurse.

10 Likes; 25,281 Visitors; 1,933 Posts

I hate to disagree with my esteemed colleague, but we do not notify family members of every new medication order. If there has been a change in medication due to a change in condition or a new psychotropic medication, we will call them. But it would be impossible to call every family member with every order change we get. On the short term, sub-acute unit, we probably get upwards of 300 orders a week.

This is what I'm having trouble wrapping my head around. We're told to call the family as well (I work short term post acute rehab) and for one, many of my patients are a&o x 3, and it's literally impossible to keep up with telling the family about new orders when many of them are initiated by the doctor via our electronic records and/or are silly, like Tylenol or zofran.

Yet, I have to make the call, because I have to chart that I've notified family, even though It would be simpler to let them know when they come visit, etc.

Whats the deal with this? especially with my self responsible patients, I just don't get it.

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TheCommuter has 10 years experience as a BSN, RN and works as a CRRN, now a case management RN.

21 Likes; 1 Follower; 228 Articles; 315,350 Visitors; 27,607 Posts

Whats the deal with this? especially with my self responsible patients, I just don't get it.
The policy of notifying family for every single new or altered order arose from a bygone era (decades ago) when most LTC patients were senile and cognitively impaired with questionable decision making skills.

Today's LTC/rehab resident mix is much more varied. I agree it makes no sense to notify family when the resident is oriented x3 or x4. However, if the facility where you work has a policy to notify the responsible party, and the resident is not his/her own responsible party, family notification should be made if the nurse wishes to adhere to the policies of his/her workplace.

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