Need Documentation Help!!

[purple_rose_3]

I need some help with documenting in Nursing Notes. I'm working on my own at the Nursing Home for the first time tomorrow night and I don't feel comfortable with my documentation. I don't know what to write about!

* A little background information* - I've worked at this Nursing Home for the last 3 years as a CNA and I just recently got my LPN. They trained me 3 days and now I'm on my own. They say because I know all of the residents that I don't need much training. I'm comfortable with passing the medications and treatments and stuff, but I'm just not to confident about my documentation and talking to the doctors on the phone.

Any help would be greatly appreciated! Thank you so much! -Andrea

[lpnstudentin2010, LPN]

OK it am NOT a nurse but here is my take...just trust yourself.

[txspadequeenRN, BSN, RN]

What type of floor do you work on in LTC? Medicare , hospice general ? When you are charting it is just the facts, no opinions. Let me know what kind of patients you have and Illhelp you!!!!

[purple_rose_3]

I'm working in a Skilled Nursing Home!

[purple_rose_3]

I just need help with routine nursing notes and what to write about when someone has a g-tube.

[Nurse Ratched, RN]

It doesn't matter how long you've been a CNA - the powers that be KNOW that a nurse's job is completely different. You need more than three days orientation. Unfortunately, they are desperate to get a warm body pushing pills. The most common technique abused by mgt in such circumstances is flattery that they word in such a way you feel unable to refuse: "You're doing so well we're going to take you off of orientation" or something similar. Please understand, I am not insulting you, just agreeing with you that three days is not enough time for a new nurse to be ready to take over, valuable tho your CNA experience is.

You need to tell your mgt that you need more orientation. Barring that, re: your question about documentation, in narratives state only facts, not your perceptions, not your interpretations. IE, a resident falls. "Mrs. Jones found lying on her left side on the floor of her room. ROM negative for injury. Baseline LOC. Skin intact. Round 5 cm red mark on left elbow. VS: 98.2 74 16 100/60 MD notified - no orders rec'd at this time. Pt states, "I got up to the bathroom and got dizzy and fell down." Dgt notified.