LFrieds

Ugh. I recognize that some patients can be manipulators but really, is that an excuse for us to be rude or abusive? 2 wrongs... First..report to your Abuse coordinator and let them do the investigation. If you don't know who that is, then ask! It's not your responsibility as the floor nurse to investigate allegations. Report off to your superiors and go about your business. Abuse is subjective, to the patient. It's his/her perspective. ANY potential abuse needs to be reported. If you suspect it, report it.:) good luck!

Ya, I'd interview the ultrasound techs or transfer team, not that anyone will claim responsibility. I had a patient once, who's cath kept "falling out or it was replaced into the lady parts"...ha! Of course urine had been draining so it was not in the lady parts! Then one day it fell out again and I asked the nurse on duty to pull the cath out of the trash and inspect it. No leak, nothing. Come to find out, we suspected the daughter was deflating the balloon while visiting. People!...document , document , document.

Hi all, I am new here an just browsing. I'm the Staff development coordinator and ADNS at a SKilled Nursing and LTC facility. I hope this helps someone. I know it helps my nurses. Skilled Admission Note Highlights: EXAMPLE1. Resident admitted to rm#___, time, from what facility, via _______ (? ambulance), # of attendants, transfer by #____ from stretcher to bed, with _______ (extensive/limited/ supervision) assist of #___. 2. Resident requires daily skilled nursing level of care R/T Dx of : list primary Dx’s 3. Mental status ie. A+Ox3 4. Mood ie. Pleasant and cooperative 5. Neuro status ie. PERLA 6. Assessment of any relative organ systems 7. VS and O2 sat: on room air or oxygen. Oxygen via _______at ____L/m 8. Bladder and bowel continence, voided? 9. Bowel sounds, condition of abdomen ie soft, Last BM 10. Appetite: ie. Ate 50%, ability to feed self 11. Pain, note level on scale of 0-10, meds given and effectiveness 12. All skin and Wounds issues: size, drainage, surround skin, wound bed, location, type, treatment 13. Weight bearing status 14. # of assist(extensive/limited/ supervision) with bed mobility and transfers 15. Lung sounds 16. Participation with therapy: PT/OT/ST 17. Does resident have a DPAOHC? Copy obtained? Document your referral to SS if needed. 18. Code status 19. 2-1/2 side rails as enablers for bed mobility 20. Oriented to call light and room 21. Orders to pharmacy 22. Sign note Daily Skilled Note Highlights: EXAMPLE1. Resident requires daily skilled nursing level of care R/T Dx of : list primary Dx’s 2. Mental status ie. A+Ox3 3. Mood ie. Pleasant and cooperative 4. New orders 5. Assessment of any relative organ systems (see BLUE skilled charting guidelines page at front of IDT notes for each note) 6. VS and O2 sat: on room air or oxygen. Oxygen via _______at ____L/m 7. Appetite: ie. Ate 50%, ability to feed self 8. Pain, note level on scale of 0-5, meds given and effectiveness 9. All skin and Wounds issues: size, drainage, surround skin, wound bed, location, type, treatment 10. # of assist(extensive/limited/ supervision) with bed mobility and transfers 11. Any changes in status and your response, ie. Called MD etc 12. Participation with therapy: PT/OT/ST 13. Sign note 3/25/10LF