Skilled Notes

[Isitpossible]

I am new to LTC w/30 patients. Three of my residents are skilled, and I was told that skilled care requires documentation every shift.. I'm really not sure what to put in a skilled note exactly...I believe its different than a general assessment? Any advice? Thanks in advance!

[TBohmRN, RN]

Ive worked in LTC for over 10 years. We do skilled assessments once a shift. My facility has a "skilled assessment" template/form on our system. It's basically a head-to-toe assessment, and make sure to focus on whatever brought them to skilled care. Vitals, LOC, heart lung and bowel sounds, voiding pattern, edema/skin, activity level & tolerance then treatments, wound, tubes & drains, incision, etc- all if applicable.

[STeagueLPN]

Does anyone else miss the old days of paper charting? Sometimes I do...I used to stack my charts on a bedside table and find a nice quiet place to do my charting instead of having to sit at the nurses station computer all the time.

[CapeCodMermaid, RN]

I don't miss paper at all. The progress notes are so easy to read. You don't spend unnecessary time trying to decipher the handwriting--although with some of the notes I've read, it might be better to not be able to read them!