What important paperwork do you use at work and would recommend to a new grad (Consents/orders etc...)

[LogicalCoconut]

I am sort of a new grad nurse. My first job was working night shift 8hrs at a behavioral health clinic and we mostly did nothing but push meds and chart about them. My position was psych nurse but there were also medical nurses who did other things such as admission etc... So I never received enough information as to everything I may need.

I now work at a nursing home and I've literally had to ASK them for everything, there's no policy/packet/book/binder for new orientees. I literally hit the floor pushing pills. That is basically it. I of course feel comfortable with the meds but I DO NOT feel comfortable about certain things that could happen and not being able to find paperwork or MISSING something that I was supposed to do.

I am extremely inattentive and need to be highly organized and have a methodical approach to my work and it is very unorganized here. Although I do like it because it's 5 minutes away from me.

So I will be writing a list of paperwork that I could possibly need during a 12 hr shift and I would like your help by telling me what paperwork you use and would recommend. One particular paperwork they're adamant about is dietary and psychotropic drug consent.

After getting paperwork in order, I will make a large binder that I will keep with me.

Thanks in advance!

[FolksBtrippin, BSN, RN]

I don't understand your question.

The facility wants you to complete paperwork but had not actually provided you with the paperwork they want you to complete or guidance on what needs to be completed?

If this is the case, you need to talk to your supervisor for this information. It sounds like you aren't getting a proper orientation.

[LogicalCoconut]

Just now, FolksBtrippin said:

I don't understand your question.

The facility wants you to complete paperwork but does not actually provide you with the paperwork they want you to complete?

They provide the paperwork, but I have absolutely no clue what paperwork they want nor where it's located. One nurse tried to help but we had so many admits that she couldn't help too much.

I'm going to see what paperwork you guys use in general and then sit and talk with my nurse manager to get a crystal clear picture. But he's out sick.

[SaltineQueen]

I'm also a little confused by what you're looking for. Paperwork is going to vary by facility & possibly unit. I'm not sure we can help you in that area...you're going to have to have someone at your place help you track down all the regularly used forms. I'd just wait until your manager is back.

[LogicalCoconut]

Just now, SaltineQueen said:

I'm also a little confused by what you're looking for. Paperwork is going to vary by facility & possibly unit. I'm not sure we can help you in that area...you're going to have to have someone at your place help you track down all the regularly used forms. I'd just wait until your manager is back.

I'm asking about what do your facility require. Of course I'm going to ask my manager. I would just like to know what others are doing.

Examples:

Side rail consents

Incident reports

Psychotropic consents

Med orders

CT/EKG/Xray order

Sending a resident to the hospital.

Etc...

[FolksBtrippin, BSN, RN]

10 hours ago, LogicalCoconut said:

I'm asking about what do your facility require. Of course I'm going to ask my manager. I would just like to know what others are doing.

Examples:

Side rail consents

Incident reports

Psychotropic consents

Med orders

CT/EKG/Xray order

Sending a resident to the hospital.

Etc...

Okay.

I think your question is specific to nursing homes then.

The paperwork I do is probably not relevant to your job at all.

Maybe you should post this in SNF category. Or maybe some nursing home nurses can answer.

[traumaRUs, MSN, APRN]

Moved to LTC

[Glycerine82, LPN]

what i did for my first job in a SNF was take a copy of every form I needed. I kept them all in a 3 ring binder so I had them to reference and make copies as needed.

[CoffeeRTC, BSN, RN]

I'd start by getting a copy of what is needed for an admit, a transfer to the hospital and a discharge. There might not be many actual papers since most things are done on EHR and then just printed out from there.

Labs are done online too. xrays are called into the company...no forms.

Event reports are done online but we have staff write out statements.

We don't use side rails, but we do have a consent form for Psych meds that is done on admit or with each new med.

many forms are going to be specific to your facility. Our dietary dept wants us to do a req form for diet changes.

We still have physicians hand write their orders.

We still do paper skin assessments weekly and weekly wound measurements.

There really aren't that many paper forms. Most of what we do is electronic forms.

What EHR system are you using? We have Point Click Care and it cuts down on a ton of paper forms.