Nursing Summaries

fiestynurse · May 8, 2001

[ May 08, 2001: Message edited by: feistynurse ]

duckie · May 8, 2001

Originally posted by netrn:
I would like to know how often you have to fill out your Nuring Summary for your residents.
We have been filling out weekly for each resident and on both 12 hour shifts because residents act differently ect.
I have been having to do mine before I start my shift- on my own or after just to keep up with them because there isn't any time at work during the day shift. Sometimes there
are five in one day to do.
I would just like to know how often others
are doing them. Thanks

We do a brief summary of care on all of our residents every week. I work in LTC so this is the guideline I use for my documentation: I include current vital signs, ADL abilities and assist required, continence level and what is done to maintain continence or toileting programs or total incontinence, mobility, current medications that require close monitoring for side effects and effectiveness, recent order changes, any change of condition or any other pertinent information that should be highlighted to bring attention to it. As second shift charge nurse I do them all, then the first shift charge nurse makes a monthly supplement documenting any differences that may have occurred on their shift. The most dramatic changes usually occur on our shift because when dealing with behaviors, sundowning, etc. the day shift nurses usually do not have such pronounced changes. This system has worked well for our facility. I usually have 6 per day. I often stay over after my shift to complete them, that way it doesn't take my time away from the other duties I have and I really don't mind, as it is quieter on 3rds and I can concentrate better.

NurseNelly · May 9, 2001

Our facility had 120 residents. About 40 residents on 3 floors. Each floor was required to do a nursing summary on each resident once a month. That was a year ago. Not sure now.

netrn · May 9, 2001

With doing the summaries weekly, we have eliminated the monthly summaries but I still

feel that dividing them up where one shift does half the summaries one week and the other shift does the other half that week and then switch residents the next week where

you would only be doing 1/2 of the paper work but also getting input from both shifts at least 2 times a month would be better and

give you more time to do one on one nursing care.

We are just now having it where there may be

2 aides on days instead of one- it's hard being the nurse and aide with all this paper work. Thanks for your input.

tinkertoys · May 11, 2001

We do a computerized summary monthly on each patient, including addressing each issue of their care plan. 11-7 does this, and the MDS coordinator handles the quarterly, change-of-status, etc. We also do focus charting daily on our skilled-care patients, addressing their general condition and priority diagnoses. Each shift is responsible for a different set of patients, to spread the load. this is all in addition to any alert charting we may be doing. Not much fun, but I guess it's necessary.

night owl · Dec 1, 2001

At our facility, where we have 60 pt's /unit, each nurse on all shifts is responsible for 5-6 residents for a computerized monthly nursing summary. Half of the summary is on a template where you place an "X" for the answers to questions like,

ACTIVITY:

( )Independent ambulation

( )Uses walker

( )Wheel chair

( ) Bed to chair

( )Ambulates with assistance

( )Uses cane

( )Geri chair

( )Bedridden

Then part of the summary you might fill the blanks like,

DIET AND NUTRITION:

current weight:

current diet order:

supplements:

EATS MEALS WHERE:

LIST ALL ALLERGIES:.....and so on and so forth. At the very end there is a section called...

NARRATIVE:

Here you describe the pt (ie) This 78 y/o caucasian male, (Dx:) with Dx of CHF, HTN, ASHD, schizophrenia-paranoid type, current vs., ADL's.Then you go on to describe any changes in his condition for the past month, eating habits/ (+) or (-) lbs past month, pt.educations, changes in behavior patterns, pain management therapy, does the resident attend any therapies, interaction with other residents any test or procedures he may have had done, any changes in medications and why, does he have any advance directives or limited therapies, DNR status, family involvement, d/c plans, and any other info that you might think is pertinent about the resident.

I couldn't imagine doing this form once a week. Sometimes the only thing that changes in four weeks is the resident's wt. We also do a nursing progress note for anything that may need documentation. (ie) pt spikes a temp, incidences that occur. you get the picture. Hope this helps!

mtgirl63 · Dec 14, 2001

In our facility, each nurse is assigned approx. 8 residents a month and we are responsible for those summaries that month.

Tim-GNP · Dec 15, 2001

The nursing summary should be done monthly. It should serve as a method to evaluate the plan of care [that is, you should write the narrative based off of plan of care goals, as to whether or not the goals are met or unmet].

The RNAC [or whoever develops plan of care] should be looking at the summaries to see if goals are being met, or unmet. If unmet, s/he should revise the plan of care accordingly.

It is really the only way of not getting a DOH deficiency.... and even then, you're probably damned.

night owl · Dec 15, 2001

Tim,

Is this what you mean? I'll use an example...The narrative would include any changes in behavior and what those changes are. (ie)Resident has become increasingly combative and assaultive toward other residents especially when refused a cigarette. Whether or not a psych consult for evaluation was done along with any changes in medications for mood modification AND whether or not the medications are of any help to the resident. (ie) Psych consult was performed on such and such a date by Dr. so n so. Upon his evaluation it was recommended that resident be placed on Valproic acid 250mg tid as a mood stabilizer. Res. has been on Valproic acid x3 weeks and has shown significant change in his behavior. Res. now has a more pleasant demeanor and interacts much better with other residents without becoming assaultive. Something to that affect. Is that what you mean by a plan of care, and whether or not this particular goal was met? Am I even close??? :confused: Please help me out here, I need to understand. Thanks,

~Michele~

Good to hear from you again!

aimeee, BSN, RN · Dec 15, 2001

Where I worked we did monthly summaries. They tried dividing them up with certain rooms assigned to certain shifts on certain days. We had so many agency people floating through that never did them that it really wasn't a workable plan. Then the unit manager would have to go back each month to find all the ones that never got done. We ended up scheduling an extra nurse a couple of shifts each month to just sit and plow through them all. Guess who the lucky duck was who usually got to do that? Yup. Yours truly. Can you say boring? We included pretty much the same stuff that has been mentioned above.

LeslieJBRN · Jan 16, 2002

NetRN,

We at our facility only do a brief nursing summary twice a year right before Full House PRI's are done. The summary includes the ADL's (as described on the PRI) and and restraints, O2 or behavioral problems. We used to do them monthly (done by the charge nurses), besides being more paperwork for them, they were often times inaccurate due to them not really knowing the info we were looking for on the PRI so we stopped the "Monthly" summaries and only the unit managers do them prior to PRI submission. We have been audited and the auditor only really looked at the summaries we did to determine accuracy of our PRI's. Nurses have enough paperwork without having them do one more piece..............good luck Leslie