Skilled Nursing Charting

Nurses LPN/LVN

Published

I have been a nurse for 15+ years and have been working at a skilled nursing facility for the past 4 months. I have never had to chart on skilled before and was not shown how the facility expected the form to be filled out. The front of the form is self explanatory (mark Y=yes and N=no). Then on the back of the form is where you put how many it requires for transfers, ADL's etc.) and then you write a narrative which apparently is where I have the problem. My DON and ADON says that I chart too much.

What exactly am I supposed to chart about then? I am so confused and can't get a straight answer out of them. If someone could give me an example of what I am to write in the narrative I would really appreciate it.

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

I work at a skilled nursing facility. Generally, management does not want the nurses to chart excessively on patients unless something occurred that was unusual or out of the ordinary (codes, falls, deaths, potentially litigious family members, etc). If I am dealing with any of the abovementioned situations, I will document as if I am writing a great American novel.

I'll usually write a short narrative about the patient if their day progressed as expected. For example, "Pt. resting in room 100 with respirations even and unlabored; denies pain/discomfort and arouses easily. No acute distress observed at this time; all V/S remain WNL, and no complaints vocalized. Staff will cont. to monitor, call light within reach, and pt. states will call PRN. Safety being managed."

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Oh, OK! Yes, I was definitely charting way too much! Thanks so much.

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