Published Nov 20, 2019
Valcorie34, BSN, MSN, RN
158 Posts
I am thrilled to be starting soon as an RCM. But I am looking for tips or methods others organize their information about their residents, wounds, interventions, falls ect. Do you usually keep a log outside of your computer system like PCC, like excel or just stick with computer? Any tips?
mander
60 Posts
Do you have a ward clerk that fills out lab slips for blood draws and appointments etc?
All of our units have a falls binder (where we pretty much just write the date of the resident's name and date of the fall as everything else is in the incident report or PCC), a coumadin binder (we missed those a loooooong time ago and got a deficiency on a survey probably more years ago than I've been alive), we used to have a wound binder but now most just keep a running list of current wounds, and the kardex is all on a kiosk so no papers around the unit. If a change is updated then it's there in the kiosk. Everyone has a separate gradual dose reduction binder for their units to track when changes are made. As for interventions, those just go along with the A & I process of ours which involves updating the care plan in PCC anyways so there's no need to track that. We do have someone responsible for tracking falls, date, times, injuries etc but we don't need to as unit managers. Much of this will depend on your facility policies.
CoffeeRTC, BSN, RN
3,734 Posts
if you keep the 802 and 672 up to date, those forms have a good bit of information on them. I will also make lists from there.