LTC - How "selective" is your charting?

[estrogen]

I'm new to LTC, just transitioned from med - surg. This one nurse, that claims to have been in LTC for about 8 years was trying to convince me that it's better to be "selective" in which events to chart and which not. For example, if someone BS was too low in the am, but you were able to bring it back up by giving them some food and OJ, it's advisable to "omit" charting the first BS, because one could make themselves and the facility much more liable in case something happened later and the chart happened to be investigated and questioned.

In my opinion this is not good nursing, because it doesn't have the patients best interest in mind and keeps the information from being concidered by the MD and/or insurance/medicaid in further treatment. ie if pt. keeps desating w/o O2, but the charting doesn't reflect that, medicaid/insurance may not want to supply it for the pt....

Am I right or am I wrong? Is this common practice? What would be the correct way to proceed in the pt.'s best interest, yet not make oneself a target in the "blame game"?

[dotty865]

This one nurse, that claims to have been in LTC for about 8 years was trying to convince me that it's better to be "selective" in which events to chart and which not. For example, if someone BS was too low in the am, but you were able to bring it back up by giving them some food and OJ, it's advisable to "omit" charting the first BS, because one could make themselves and the facility much more liable in case something happened later and the chart happened to be investigated and questioned.

:uhoh21: Never Never Never do this . nothing should be omitted from your charting .

..... chart your full assessment ! then you won't be :chair: or

[estrogen]

Thanks... I agree. I didn't think that was appropriate nursing.

[Nascar nurse, ASN, RN]

Definately cover your a$$ and the only way to do this is with complete and honest documentation. If everybody fails to document a "low blood sugar" and just fixes the problem, the insulin orders will never get changed and eventually the resident will suffer when someone doesn't "catch" that it has gone too low again.

[dinkymouse]

I still don't know everyone in my facility. I hate it when I need to see if something is normal for a patient and its not documented if it has happened before. I want to know if someone has a low sugar because if it happens often something needs to be done. It is difficult to tell family members answers to questions if I don't know what is going on.

[Daytonite, BSN, RN]

This one nurse, that claims to have been in LTC for about 8 years was trying to convince me that it's better to be "selective" in which events to chart and which not. For example, if someone BS was too low in the am, but you were able to bring it back up by giving them some food and OJ, it's advisable to "omit" charting the first BS, because one could make themselves and the facility much more liable in case something happened later and the chart happened to be investigated and questioned.

Good lord! How about "selective license termination" starting with hers? This 8 year veteran needs to go out with the trash. You are absolutely right. You do exactly as you were taught in school. Chart all the facts regarding what you do for a patient--always.

If this nurse is one of your co-workers I am suggesting that you tell the DON what she is advising you to do. She is not only giving wrong advice, but if an incident ever does occur, based on what she's told you, the nursing home would get taken to the cleaners by a clever attorney. What a dimwit!