New Rn and LTC charting

Hmm...are these long term care residents or short term rehab residents?

Can you ask what their expectations are? Doing a full head to toe assessment on each patient isn't realistic in LTC where you have 30 patients.

The charting is so different for routine LTC charting vs. Medicare LTC charting that I would need to know which type you are charting on.

I guess my point is, I don't think she checks the others that have been there a few year....is she hating on me or trying to make me better. If better, she is deflating my self confidence and I am thinking of moving on. So confused. I have asked her several times about what she needs, I always think I have it down and then BAM!

Altho it seems that way. don't take it personally. Newbies are the ones who need the closest supervision & direction; the other staff are probably OK with their documentation so she's not as critical with them. Because our documentation drives reimbursement and can be legal 'black holes', she's focusing on you to get you up to 'snuff.

Charting from nursing school to LTC is a BIG transition; charting from hospital to LTC is a BIG transition, differently, also. And it takes time to get the hang of what's necessary stuff & what's fluffy stuff when charting. Also you don't want to write anything that can come back to bite you, another coworker, an MD, or the facility. There are good ways to write about problem things. That's why she's checking.

In all my eon years of nursing, I still occ read a nsg note entry just that takes my breath away!!! I notify the DON/ADON ASAP of what I've read as I believe it jeopardizes someone. If I see an omission, I'll notify someone to get it fixed. As a professional, I don't want to see a peer or my employer have problems.

Just know that even we Old Ones sometimes get stumped on how best to write a note. Upon rereading my notes the next nite, I'll think, boy, I could have said such & such so much better. And we do forget an entry every now & then. But we try to fix it.

I'm sure there are resources out there for you to follow - I'm not the best person to direct you that way. I know AN here has had numerous posts on charting. And a tip might be for you to read a few nsg not entries ahead of you to get a few ideas or direction. Also find someone you think charts well and use their notes as a sample.

Good charting is a skill to be acquired, just like venipuncture & inserting foleys. It takes time & practice. Good luck & keep at it.

Thanks for a good post and good advise!

Have you asked her to sit down with you and show you what she is looking for when she checks documentation? I have found this to be one of the best ways to learn what info is necessary, what is fluff and what is potentially a landmine. If she uses an audit checklist/tool and she will allow you to "coaudit" some nurses notes alongside her then you can really hone your own charting to focus on the critical info required and present that info in the most concise, clear and appropriate fashion.

For LTC charting, here are a few common things she might be looking for (mostly for medicare charting/MDS) .

1) Is the resident alert and oriented x 3 or are they confused?

2) Do they require assistance with ADL's? If so, how many staff is required to assist?

3) Are they on an antibotic? If so, for what and is there any adverse reactions.

4) Did they take their meds and tolerated them during your shift?

5) Any dressings or treatments ? Even if you personally did not change the dressing, note the location and condition of the dressing.

6) Does the resident have a mid line or picc line? Did the line flush with or with out difficulty.

7) Check the resident's primary dx and make a note related to the dx.

8) Is the resident continent of bowel an bladder? Foley?

Here is an example documentation for a resident who is s/p ® hip ORIF.

"Resident is alert with confusion. Resident requires assist of 1 with all ADLs. Resident is up ad lib in w/c and able to move independtly in w/c throughout facility. Resident currenlty on ABT PO for UTI with no adverse reactions noted this shift. Urine noted to be cloudy. Temp 98.9. Resident denies any urinary discomfort. All meds given as ordered and tolerated. Writer noted dry, intact dressing to ® hip. Resident c/o ® hip and PRN pain med given x 1 this shift with effective results. Resident incontinent of bowel and bladder. Peri cares provided by 1 staff assist and resident is on toileting program. Resident is currently resting in bed with no s/s of pain or distress noted at this time. All safety measures in place."

Here is another example:

Resident is AAOx3 and is able to voice needs to staff. Resident admitted yesterday s/p total (L) knee. Dressing noted on (L) knee to be dry and intact. No redness noted. Resident is continent of bowel and bladder and reguires set up assist only. Up ad lib and currently in physical therapy. All meds given as ordered and tolerated. Writer encouraged resident to use call light to call for assist prior to transfers. Safety measures in place.

One more example

Resident is AAOX3, able to voice needs to staff. Assist of one with ADLs. Noted to have COPD. Lungs are noted with rhonchi, sats are 89-90% on 2L/NC, HOB elevated. Resident denies any resp. distress this shift. Noted to be in bed, watching TV most of shift. Family visited. All meds given as ordered and tolerated. Writer assisted resident to reposition in bed and enouraged fluids. Safety maintained.

Hope this helps!!

Trust me, take this opportunity to learn from her. I have a DON who is ALL over charting (and I have lots of experience but as I am per diem sometimes I miss something) and she is right there to remind me! Cannot take it personally. It will wear you down.

Here is what I give my nurses to use to chart on Medicare/skilled residents. You only need to chart in one place....not on the MAR and in the nurses' notes

DAILY SKILLED DOCUMENTATION GUIDELINE.pdf