Start in LTC next week what do I really need to write for nursing notes?

[KRODD]

So I start next week in LTC that I worked in as a CNA while I was in school. My question is what do I write as a narrative note for a long term non rehad pt. that nothing is abnormal for the pt. that shift. I have ordered the "Mosbys surefire book" and "Chart Smart" from amazon that will come next week.

My question is do I not have to write a narrative note, if theres is not anything to update in the pt. chart. If so what do I actually write?

[csrs_nurse]

My question is do I not have to write a narrative note, if theres is not anything to update in the pt. chart. If so what do I actually write?

I have worked as an LPN in LTC (Louisiana) for three years now. In my experience, a nurse entry should be written every shift while the resident is skilled, within the "look-back" period, newly admitted, or recently returned from a hospital stay.

If the "non rehab" resident you are asking about does not fall into any of these categories, you may not need to write a narrative unless something significant occurred during your shift. I would ask my nursing director or the MDS/Careplan nurses to be certain. Usually, there is a charting schedule for residents who are not in the window for daily charting.

Best Wishes,

Sonnie

[lpnshortygurl]

I have been an LPN 8 years but I have only worked in 2 facilities during this time. Both facilities were completely different on what was required in daily documentation. I believe the facility where you work will have a guideline as to what is expected of nursing for notes. At my first job we were required to do a full narrative on such things as orientation, level of care, max assist or min assist, continent/incontinent, vital signs for anyone who is medicare, pain, any prn meds given, etc etc.. At the facility in which I am currently working, they divide the patients between the 3 shifts and the nurse is only required to put a set of vital signs in the chart unless the patient is medicare in which case we fill out a daily medicare check off list that basically has all of the above items I mentioned. Hope this helps you out a bit..

[caliotter3]

You will be given the required info during your orientation. If it seems they are leaving anything out, ask specifically. Also, your supervisor will make certain you know what is expected of you once you start working on the floor.

[KRODD]

Thanks makes alot of sense.