progress notes

[hardware syndrome]

Can somebody give an advise regarding documentation in progress notes.

Can i write everything even if it is almost pages long!

[Daisy_08, BSN, RN]

Probably not, but it would depends on the situation. If you are new to this facility, look at how others write them.

Also progress notes are meant to be read, no one is going to get through pages.

Maybe you could be more specific.

[dishes, BSN, RN]

For a better understanding of what you need to document review your workplace policy and procedures. Also, CNO has a variety of education resources available on their website, look up the 'Documentation' learning module, webcast and/or practice standards booklet.

[hardware syndrome]

I work in a LTC, lots of situstions that always needs documentation. I dont want to write all the details, just to cover me.

[dishes, BSN, RN]

Have you read Commuter's article on LTC charting? It is based on American LTCs but many of the tips apply to Canadian LTCs https://allnurses.com/geriatric-nurses-ltc/ltc-charting-a-899111.html

For specific tips on the legal aspects of Canadian charting, look at the Canadian Nurse Protective Society they have publications, case studies and quizzes, they also have an upcoming webinar.

[Silverdragon102, BSN]

I work LTC and we use DAR process and works very well so a lot can be written without writing an essay

http://www.wrh.on.ca/webbuild/site/wrh-internet-upload/file_collection/Focus%20Charting%20Review.pdf