Specialties Geriatric


Specializes in Transitional Nursing.

I figured I'd start a new thread incase others have this question also. 

With the implementation of PDPM we've gone from medicare notes once per day, alternating between shifts to notes q shift. 

I'm really running out of things to say about these folks besides the exact same thing I wrote the day before or the shift before me wrote. There are only so many ways you can document lung sounds clear, Sp02 96% on 2l/NC. Participates with therapy.  Or is that enough?   Seems pretty redundant. 

How does your facility do it?  Its pretty excessive, at this point.  I think I have like 14 skilled notes every day.  I usually take pride in my narrative notes, with attention to detail for the reasons that warrant skilled care but sometimes I feel like a parrot. 

Specializes in retired LTC.

Remember that you're NOT writing the next Great American Novel! My notes on NOCs were sometimes repetitive, but that was because my pt care reflected pts who remained pretty much the same nite after nite.  Notes didn't have to be fancy, just descriptive & comprehensive to cover the necessary documentation requirements.

Of course, paper charting is diff from emr charting. Perhaps your Staff Devel or rehab staff might have some samples?

Usually my assessments stay the same, I write note in that one can depict how that day went for the resident. I include medications I given to them that day, note no side effects, etc. Their mood, any visits or activities they did. Because  when I read therapy notes I see exactly what they did that day, so I try to write the residents day so when someone reads it they kinda know what the resident did that day r/t nursing 

In addition to vitals and general stuff, if it is a Medicare coverage stay, I always charted to the reason that they are admitted I.e. wounds, tube feedings, rehab etc.  If they're on antibiotics or recently had a fall or any other COC, I do a focused assessment pertaining to that COC.

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