Resident Participation/charting

[Kepu 0]

Hey guys!

My name is Karen, and I have worked in an activities department for 17 years, but just recently took over as the Director.

Our problem lies with charting for the residents.....its killing us! I know there are different ideas/suggestions and ways to do this- but my question is this....

Does anybody know the certain rules and regulations- specifically for this??? I am concerned my department is doing way more than we have to....We chart EVERYTHING- from group activities they participated in, to every "little" thing we do for them throughout the course of the day. If we see them for a visit- we chart it- but we also chart errands, family contacts, walks, radio, comfort measures....all those individual things.....IS THAT NECESSARY??? Do you all chart that much for every patient....or are we going above and beyond?? Just wondering what is required of us exactely???

HELP!!??

[Guest Tinki]

Karen,

 

What type of Facility are you working for?

 

Karen

[Kepu 0]

Hey Karen,

I work for a skilled nursing facility- 200 beds.....40 of them are for subacute patients- the rest are for long term care. I really think we are going "over the top" as far as all the "individual" things we are charting on- it just takes us forever- and if we run out of time- and miss a group or two....UH-OH....Cuz then we're even more behind the next day!

Does everybody chart every single little thing- they do for every single resident/patient???????????? Or is it just us wackos up here in New York????? :-D

[Stacy 0]

As far as charting everything that is done, a narrative is not needed. That's is what quarterly notes are for. You should write a brief note if you speak to the family for specific things such as outings or something, but again, not everything needs to be charted in depth. I have my assistants chart extra when there is a behavior that occurs in the activity, or if they fell in the activity.

 

For individual visits, we have a form for those that are seen 3x's per week, and we use a check mark/code for it. The same with group attendance. It's good practice with what you are doing, but, no, you do not need so much documentation.

 

I have a 99 bed medicare unit, and when I first came to this facility, my girls were writing monthly notes on every one that was admitted to the facility. I was afraid to stop it, but I had a talk with the Administrator just this past week, and that in its self was extra charting for them. So, we now have stopped that.

 

 

As a Helath Care Profession, we do chart a lot. Some of it is required, and others is because of what has been done in the past. I know for us, the only requirement for charting is Admission, Quarterly, Annual, and Significant Change. Everything else is extra.

 

Hope that helps.

 

Stacy

[Guest tigger]

Hi Karen, I live in Oregon and was an assistant for over a year, now Im doing the AD. I think you are worring to much about your charting. Im not sure about your rules because I think every state is diffrent, but I chart all my large groups, my sensory, visitors only on my 1-1s, my outings. They cannot exspect you to do a good activity and also try to remember all the little stuff. You can however do that little charting on your summery. I think you just need to talk to your administrator. I have a really cool administrator, and she only has me do enough to please the state, and that gives me alot more time with my residents. But then I dont have any one but me doing activities.