LTC "Brains" Do you use one?

pinkiepieRN · Aug 29, 2013

I work days but I too live for a "brains" and call it such, lol. We have a "shift to shift" report sheet we can print out with three blank columns next to each resident's name and room. I take report in the first block for each resident. I write down who needs morning vitals and fingersticks in the first column and lunch fingersticks in the second column. I put 2pm meds and treatments in the third column. I often highlight all of my tasks in yellow and then highlight again in pink when I've completed the task. If I'm stressed, I do end up making a checklist for tasks I still need to do. The MARs and TARs are all paper for us, but we do computerized notes. I tend to only chart of residents who are on ABT, s/p fall or anything else out of the ordinary.

LittleMamaRomeoRN · Aug 29, 2013

15-25 patients isn't too bad! It is different than a hospital setting, unfortunately you don't get as much 1:1 time with your residents, but you will find a way to get it all done. If the facility has a shift report sheet, USE IT! If not, I'd suggest making one at home to print out and use at work. Until you get used to your residents and remember everything about them (and you will, trust me) you can make yourself a cheat sheet. Write down who gets glucose checks, how each resident takes their medications (pudding/applesauce, whole, PEG), and make sure to mark who takes thickened liquids and the consistency. Mark who will need skilled charting, behavioral charting, and antibiotic charting. I also used to mark who I needed to check parameters for for specific meds ( pulse for Dig or BP for BP meds etc.) Bellaluna's suggestion of highlighting or using different colored markers/pens is a great idea as well! You'll get your own system, and it will be amazing to you how well you can manage all those residents! Good luck!

Ginnym1981 · Aug 31, 2013

Thank you both! These are some great suggestions :)

workinmomRN2012, BSN · Sep 4, 2013

On our rehab floor we have 30 pts when full. Shift report sheet is a Godsend, you can write next to the name if they BS /ABT/crushed meds etc. As long as you are organized you will be fine. My med pass is usually 1.5 to 2 hrs. We have a tx nurse that does wounds, but I still have to do the skin preps/lotions. I work 3-11 and I don't get paid after 11pm (unless it's an emergency), I usually don't work past 11:20- that's after I give report and count narc's. Good time management skills go a long way in SNF/Rehab. Good luck :)

JBMmom, MSN, NP · Sep 4, 2013

I usually use one shift report sheet for taking notes from the shift I'm taking over for, and then a blank one to right down what I'll pass in my report and what I've done. I'm a check box person, so all my treatments/dressings/etc. I write down next to the residents's name and add a checkbox so I'll know when it's done. I'm also second shift and since there are two med passes I right slash after the first med pass and left slash after the second so I can easily see if everyone has an X at the end of the shift. Some people I work with use a highlighter, for some reason my brain can't process the highlighting as easily as an X.

As for notes, I'm only charting on Medicare residents that those that are on report for a change of condition (or id I have to add them). If you're paper charting, I'd read through a few past notes from nurses that you think will set a good example and see what they wrote. One piece of advice I got from a class was DO NOT chart "will continue to monitor", because once you leave the building you're no longer continuing to monitor and you can't chart what you will do, only what was done and what did happen. Be concise and descriptive, it's no English essay, just the facts.

Good luck! Hope you enjoy your new job!

chrisrn24 · Sep 5, 2013

Yep don't chart "continue to monitor."