Reporting in LTC/Brain sheet

[ana_espana]

I'm an RN who is new to LTC (skilled nursing/rehab) after 2 years of experience in a post trauma/Med-Surg. I have been orienting for a week and I'm wondering, how do you keep track of important information for each patient (w/o electronic charting). In med surg, we had a sheet for each patient, covering all basic info, organized by body system. It was written w/a pencil and each RN would update the page as needed. It was an easy way for me to get a snapshot on all nursing related issues affecting each patient and I could get an overall idea of the patient's challenges/issues/care plan in about 1.5 minutes. This sheet was initiated @ admission by the RN and added to as time went on. The sheet did not go into the patient's chart..it was carried around by the RN, then passed on to the next shift. In this LTC facility, it would take me at least 30 minutes per patient to figure out BASIC information (last BM, prns, main diagnoses, family issues, fall precautions, patient priorities, important details, etc). This info is in at least 5 different locations, the chart being only one of them. I don't have time to search through 20 patient charts to find basic info that was not passed on to me in report. Also, there are small but important issues w/each patient that are never kept track of because each RN experiences such different issues w/the patient depending on the shift. With 15-20 patients, a detailed system-by-system report sheet for every patient is likely too much to ask for an RN to update in this setting...but I'm wondering, what do you do in your facilities...particularly those w/o electronic charting? ANY ideas for brain sheets/RN report sheets would be greatly appreciated!

By the way, while I'm orienting on a floor w/a 1:20 ratio, I will eventually be moving to a brand new floor, 1:10 ratio, w/skilled nursing/ortho rehab patients with acute needs. It will be even MORE important to have a quick way to find important data.

And here is my two cents about LTC so far...LTC/rehab is NOT 'easier' or for 'less skilled RNs' as I had heard before in more critical settings. It is a busy, diverse, challenging place that requires beyond exceptional people skills. I can't believe hospitals would ever discount experience in LTC. Sure, you aren't running around w/powerful IV drugs and constantly dealing with acute changes in condition as frequently but, it still happens....and you figure it out w/even less resources. If someone passed out in the hospital, I called a Rapid Response and BANG -- a team of docs/crit care RNs arrived to the rescue in seconds... I could sit back and be the resource person. In LTC, you better know what to do. I'm also finding the providers in LTC to be really communicative and more willing to teach. They aren't as rushed. Personally, I think it's fantastic experience for anyone and I'm looking forward to boosting my skills/getting to know the patients in this new setting. I'm seeing lots of RNs choose LTC because they are new and can't get a job in a hospital yet. They keep asking me, WHY did you switch to LTC? For all of you who are new...the first 6 months are beyond stressful no matter where you are. The right RN setting for you depends on what is important to you - that's it. If you like lots of tubes, analyzing diagnostic tests and problem solving through crappy ABGs, lab results, vitals, etc....and never talking to your patient- crit care is your baby. If you like OCD-type order and technology, then surgical nursing might be is for you. If you like getting to know your patients both medically and personally, and offering much needed physical/psychological comfort as they deal with chronic issues... try out LTC. It's too bad so many RNs feel like LTC is a 'last resort' during the job hunt. It's just one of the many different ways of being an RN.

[CapeCodMermaid, RN]

Thank you! You get it. We are not a bunch of morons handing out tylenol and colace. It's hard work and getting harder by the day. We have a one page unit roster on each floor. Basics such as MD, code status, and how they take their pills is on the sheet. It's worked for me for years. In one building we used a Kardex system but the Kardex stayed at the nurses' station. Whatever works for you is what you should do. When I worked the floor I would take report in one color and then throughout the day, whatever I added to my sheet for my shift, I'd write in a different color...prehistoric but it worked. We are soon to go to all EMR. Each nurse will have a small laptop or tablet to carry around so ALL the information will be at our fingertips. Good luck.

[teeniebert, LPN]

The facility where I work uses a 24-hour report sheet with a row for each resident and a column for each shift. Code status, MD, and case manager are printed under the resident's name. I grab an extra one before report and use the '1st shift' column for info I get in report, the '2nd shift' column for info I get during my shift, and the '3rd shift' column for things I need to do (ex: the resident gets blood sugars checked at 0730 and 1130 and has a Mepilex dressing on her coccyx that I need to change this shift. I'll write in 'BS 0730______ BS 1130______ Mepilex (coccyx)' in the 3rd shift column and fill in the blanks/cross off tasks as I go).

[laderalis]

We use a sheet of legal size paper that lists each resident, doctor and then three column's (one for each shift) and we put things such as dressing changes, PRN's given, blood sugars, appt's, new orders anything important/exciting that happened. we keep about 4 days worth on the clipboard and then our DON keeps them in a file, but they aren't part of the med rec or anything like that.

It's an extra place to write things down (we use paper charting), but it is GREAT to have the blood sugars, pain meds given, etc for the last few days in one clean spot.

[laderalis]

Oh, and thank you for the compliments toward LTC. I am a new grad and fell into LTC after no luck in applying to acute care. I've been working about 1 month and I LOVE it. I love the mix of med/surg and mental-health nursing it feels like. I feel like I do more for my patients in the LTC setting than I did in the hospital setting.