Skilled Notes

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12 Posts

Has 17 years experience.

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.


5 Posts

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

6,090 Posts

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience.

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!