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welchkin67

Desperation!!!!

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:( Was wondering if some of you might be able to help me. I have never worked in a nursing home before only a ALF. So the documenting is different from a nursing home. Couold someone please tell me how often you are suppose to document in resident charts if they are not one on ones. And any additional info will be appreciated. Thank you all for your assistance.

 

 

Sonia Welch

Brownwood, Texas

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Thats a question you can bring to your MDS Coordinator. The IDCP team will meet Quarterly to discuss each resident and at that time each discipline will include a note in addition to completeing the MDS. There are also notes written for 14 Day assesments and for significant change assessments. Hope that helps a little but I would ask someone in your facility.

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:( Was wondering if some of you might be able to help me. I have never worked in a nursing home before only a ALF. So the documenting is different from a nursing home. Couold someone please tell me how often you are suppose to document in resident charts if they are not one on ones. And any additional info will be appreciated. Thank you all for your assistance.

Sonia Welch

Brownwood, Texas

 

 

Hello Sonia,

Documentation of activities that one has attended is done on a daily basis. Exactly what kind of documentation are you talking about?

Documentations on behavior if a resident should have one during an activity, is also documentated on a daily basis.

 

Documentation is very important for MDS purposes, facility purpose and employee purpose. If you have any specifics that you are confused about, we will try to help you anyway we are able too.

 

Sincerely,

Kanela, ADC

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The federal government requires you to do an initial assessment (no later than day 14) and then assessments every three months after that (called "quarterlies" and "annuals.") Your MDS Coordinator will let you know when you might have to do a "significant change" assessment also.

 

Every resident should have a care plan no later than the 21st day following admit - it can and should be updated as often as necessary so that it still fits the resident.

 

Some nursing homes use forms for initials, quarterlies, significant changes and annuals. Others write narratives, giving the documentation a title so the reader knows which of the above mentioned assessments the note represents.

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Hi! I came from Assisted Living also, so I feel your pain:) You will get in the groove... don't worry!

As everyone mentioned above, your MDS coordinator should give you a calendar each month listing the residents who are due for a quarterly or annual review. Our quarterly reviews are a narrative and our annual review is a 3-page assessment & narrative. This varies from facility to facility.

 

I know the paperwork seems overwhelming! It is SOOOO different than ALF. I've been at the nursing home 3 months now, and I am still adjusting.

 

Maybe set up a meeting with your administrator if he/she is approachable, and/or your MDS coordinator. Our Social Worker is also a huge help to me...

 

I also try to attend all care plan meetings... this will ensure you are up-to-date on your charting.

 

As for daily participation in activities, that is a lot different than ALF also. I always just had to chart by expection at the ALF. At my LTC we chart daily on the residents' activity. At the beginning of each month I make a copy of the activity calendar with an individual/1:1 activity record on the back for each resident. I place them all in binders by room number (we have 4 halls, so I use 4 small binders) and each day I go through each book and highlight the activities the resident attended, the activities the resident refused and the activities the resident was unavailable for. I have them color-coded. I then flip the page over, and if the resident had a 1:1 visit or was working independently on something I list that information there.

 

Feel free to email me if you have any questions. I'm always happy to help if I can!

Kelly:)

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Sonia,

 

My first piece of advise would be to stay on this site.

 

Then, find someone who has been in Texas (Pennie I am talking to you) to help you with the state regs. This job is a learning process, find others who have been in the biz and learn from them. Then modify your skills to the way that you like to do things.

 

 

Hope this helps.

 

 

bigchris

 

 

 

 

 

:) Was wondering if some of you might be able to help me. I have never worked in a nursing home before only a ALF. So the documenting is different from a nursing home. Couold someone please tell me how often you are suppose to document in resident charts if they are not one on ones. And any additional info will be appreciated. Thank you all for your assistance.

Sonia Welch

Brownwood, Texas

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