zippy79

I know this thread is rather old, but I'm hoping someone's out there still browsing it. I recently made a switch from doing 1 year acute care to doing geriatric care at a SNF. I'm not sure if it's my mind set having been trained as an acute care nurse, but the NURSE'S NOTES section on a patient's chart at the SNF I work for always drives me CRAZY! I've read people chart things like the following: -Resident's skin afebrile (*****) -"Resident resting comfortably in bed" when the chart is tagged for tracking uncontrollable bleeding due to coumadin therapy And the list goes on... The question is, should I be writing an inordinate amount of narrative on a chart--- like "the patient was asleep in bed. blah blah blah"? I thought the whole point of nurses' notes is to chart by exception and focus on acute changes which are far more pertinent than the normals? Please shed some light on this topic....