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monthly summaries in LTC

Posted

Specializes in Med Surg, Homecare, Hospice.

Do you all still do monthly summaries and if so,what is the format you use? Ours are 2 sheets-front and back-one sheet is for the narrative.It seems to me that most of the staff is writing the info on the rest of the sheet....

We still do monthly summaries. Is the front a check list, like an assessment of different areas? The back for narritive notes should address the care plan or you have no way of showing your reviewing it to see if it's working.

Example: Care Plan #2

At risk for skin break down

The resident is compliant with turning and positioning. Orders include VitC and Zinc, tolerates well. Resident on toileting program and is provided peri care after incont. episodes. Using a BSC at night. Intake 75-100% ect.......

Continue current plan of care.

This is tour oppertunity to address with the care plan team if a care plan could be D/Cd or added or changed.

Did the resident meet the goals of the care plan?

Are they clear and realistic?

Do they need to be revised?

Address each care plan. ;)

ktwlpn, LPN, RN

Specializes in Med Surg, Homecare, Hospice.

Originally posted by caffine addict

We still do monthly summaries. Is the front a check list, like an assessment of different areas? The back for narritive notes should address the care plan or you have no way of showing your reviewing it to see if it's working.

Address each care plan. ;)

It seems so redundant-that is exactly what we do at team-and that is every time we turn around-yrly,quaterly,significamt change,etc....

The charge nurses at our facility write the monthly summaries. It just a narrative note reviewing vs, weight, intake, skin, pain etc. No form to fill out, no muss, no fuss.

Does anyone do weekly summaries? We have a new DON and she just switched from Monthly to weeklies, and needless to say we are falling far behind! And again very redundant!

At our facility, the LPNs do a quarterly summary that addresses all goals and how the res is doing related to the goals on the careplan. They are scheduled to be done right before the quarterly MDS assessment.

The RNs do monthly assessments - a check-off sheet (done q3m) that highlights all areas and a small narrative on the back for the second and third month that just addresses any changes from the quarterly assessment. These are also done prior to the quaterly MDS.

In our 121 bed facility, we do monthly summaries. Ours are one page...front and back. The front is like a checklist re: careplan. The charge nurse, writes the number of the careplan, checks yes or no if the goal is met, on the side of that, is an area for notes..relating to the care plan. The other side, addresses any changes in that resident for the past month. Here they will write done is there were any abnomal labs, med changes, etc. Bottom section is for vital signs and assessment. We also...started having our supervisors personally hand out the summary to the charge nurse ..then at the end of the shift..when the supervisor goes around for last report..she checks to make sure the summary is done. If for some reason it couldnt get done..it goes on report for the following day..and the supervisor checks the following day. Besides shortening the form...having the supervisor more involved..has really helped...and they are getting done. Tracy

trasestry@aol.com

I'm a DON in a 160 bed facility and I did away with monthly summaries. I too found them redundant and not helpful. The patient is reassessed quarterly or with significant change. I'd rather have a nurse doing a several daily quality nurses notes then taking the majority of daily charting time doing filler work.

Talino

Specializes in ER CCU MICU SICU LTC/SNF.

Originally posted by ChainedChaosRN

I too found them redundant and not helpful. The patient is reassessed quarterly or with significant change. I'd rather have a nurse doing a several daily quality nurses notes then taking the majority of daily charting time doing filler work.

Knowledgeable confident and responsible DONs think this way! KUDOS!

Ours are not too bad, we do them Monthly on everyone (120 beds) and we basically go by the careplan and chart on why or why not the pt has reached his/her goals and take v/s it is narrative in the nursing notes and really doesn't take too long.

We still do monthly summaries, and to be honest, I can't stand them. If there has been no change with the resident, they are very redundant and most of our residents haven't changed in months. Chaos, I could marry you! :chuckle

catlady, BSN, RN

Has 21 years experience.

If the nurses are documenting consistently on their residents, then I agree that monthly summaries are a waste of time. But on a stable resident where nothing "exciting" happens, that monthly summary may be the only nursing documentation when it's time for that annual MDS. It's not fun doing RAPS with no nurses' notes in the last year.

The forms in our building, however, are a total waste of time. They use a Briggs form that is just checkoffs, with almost no useful detail. But I'm not the MDS coordinator or the DNS, so I have no say in what goes on.

Our monthly summaries are also narratives in the nurse's notes. We address each careplan. Our DON has made a calandar schedule. Each day of the week, one resident gets a monthly summary done. She has it split up so that each shift has just about the same number of summaries each month, so it's fair. It typically means one, sometimes two a week for each shift.

I'm a DON in a 160 bed facility and I did away with monthly summaries. I too found them redundant and not helpful. The patient is reassessed quarterly or with significant change. I'd rather have a nurse doing a several daily quality nurses notes then taking the majority of daily charting time doing filler work.

:uhoh3: We haven't done monthly summaries for a long time. There is not a reg to do so. We just have to do our mds and watch for sig changes. It is a waste of time and not needed. I applaud you for getting rid of them.

Susan

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