Need help with charting coc

[justjosy]

Hello, I'm new to working at Nursing Homes facility. I am not familiar with charting COC, Medicare, Weekly Summary. AM I SUPPOSED TO DO HEAD TO TOES ASSESSMENT or just vital signs, see if they are in distress or if they are having SOB OR IN PAIN AND SUCH

So, we have a specific patient for Weekly summary, Medicare, Change of Condition. Am I supposed to observe patient while giving medication of that specific patients for charting and do ASSESSMENT on them so I can chart them?

In the COC there would be patient on ABT or other things to look out for. So do i focused on that ABT therapy and VS

Like how do I chart put in the COC charting?

I would like a guideline on how to do these things PLEASE!!!!!!!!!!!!!!! I AM DISPERATE FOR HELP. So when I start on my own I can do this easier and I am almost going to be starting on my own and I am so nervous because there are also patient in O2 and if the order says apply 2 liters via nasal cannula I DO GIVE IT RIGHT?!!!!

PLEASE PLEASE PLEASE!!!!!! HEEEEELLLLPPPP MEEEE!!!!!

THANK YOU SO MUCH IN ADVANCED!!!!

[roser13, ASN, RN]

Your facility will have its own Policies & Procedures for charting. Reading those and asking/observing your preceptor are the accepted ways to learn how to chart. No one here (unless a co-worker) could correctly answer your charting questions. For instance, I don't even know what COC is.

You will also need to ask your preceptor to review MD Orders and implementing them.