JustBonny

Hi Darcy: You need to read the Department of Helth recomendations for your state or the requirements of your payor (medicaid or insurance etc.) You must stick to the strongest set of regs that apply. In NY we need to keep all records (for adults for 7 years). Out records must include: MD Orders, Med Administration Records, Nurses' Notes (only your own) I&O (if applicable), Treatment sheets, The only difference between the chart the provider keeps and the chart in the pt's home is that you need only your own notes, not the other nurses. You do need all the MD orders of course, no matter who obtained them.

Hi Bonjon, I just registered with this site today too. I work as a pediactric vent nurse (for an agency) and love what I do. I, too never expected to love peds, but I would not want to do anything else now. I look forward to the future postings on this site. It looks great!

PS. I also work as a shift nurse for an agency, and the agency is responsible to maintain all these records. The nursing supervisor is responsible to update the 485 every 2 months and make sure all MD orders come back signed.

Hi I work as an independent provider of RN shift care within Homecare. We must keep up to date med sheets indicating all meds given. If the meds are given by a family member, we chart F="Family Responsible or a check mark= for "By Others"