weekly documentation in ltc

[dekatn]

I need advice, we are required to do a weekly summary on each of our pt. Each shift is assigned a certain number of pt. so that all pt in facility are documented on weekly. My problem is, the documentation is so redundent (sp?). How do others document this often without saying the same thing over and over again. I'm feeling really incompetent with my documentation as some of the pt. hardly ever have any changes, they've been on the same meds, same diets, same adl regime, etc, etc,.

[CoffeeRTC, BSN, RN]

We used to have to do weekly on all residents. It does get repetative since may of these people stable ltc res. Even if you did a check off, it probably would be the same week to week.

[Lovenursinganyx]

I work in LTC and we also have to do weekly summaries. But it is only on our skilled res. Most of the time we do have either increases or decreases in ability, so there is something to change on the form. For the ones that havent changed, there is no sense in beating yourself up over having to write the same thing over and over. We have to do MDS charting on everyone every shift so I completely understand the whole redundence that you speak of. So much time we would be able to spend taking care of these people if we didnt have to sit and think of something different to write about them. I know this doesnt help much, but thought i would drop it in! Good luck!

[Marti Ann]

I review medical records and charts on a regular basics for Nursing Homes and ALF's. Can you put in your documention, assessments of the resident's that are postive. example: what the skin looks like, so there is no pressure sore evidence.We are so use to as nurses putting what we see, how about what is not there in your assessment, that the resident is healthy, going to play Bingo, can eat meals or not. Think of the good old head to toe assessments we learned in nursing school. pick one or two and focus on them.

Just my thoughts.