Shiawassee County Medical Care Facility
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Charting and Documentation
Personnel Authorized to Record Data
1.
2.
3.
4.
5.
6.
7.
Physicians (i.e., M.D., O.D., Dentist, Podiatrist, Ophthalmologist, Psychologist, etc.)
Nurses/Nursing Assistants
Dietician/Food Service Supervisor
Therapists/Therapy Assistants
Activity/Social Services
Pharmacist
Others as approved by the administrator
Purpose
The purpose of charting and documentation is to provide:
1. A complete account of the resident’s care, treatment, response to the care, signs, symptoms, etc.,
as well as the progress of the resident’s care.
2. Guidance to the physician in prescribing appropriate medications and treatments.
3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided
to the resident.
4. Nursing service personnel with a record of the physical and mental status of the resident.
5. Assistance in the development of a Plan of Care for each resident.
6. The elements of quality medical nursing care.
7. A legal record that protects the resident, physician, nurse, and the facility.
8. A source of all resident charges.
Rules for Charting and Documentation
1. Chart all pertinent changes in the resident’s condition, reaction to treatments, medication, etc., as
well as routine observations.
2. Be concise, accurate, complete and use objective terms. Avoid brevity, monotonous, and
meaningless entries.
3. Document only the facts. Use only approved abbreviations and symbols.
4. Chart as often as necessary and as the need arises.
A. Medicare—Chart daily. All three shifts must chart. (i.e., vital signs, eating, condition of the
resident, etc.)
B. Medicaid—Must chart at least monthly a nursing summary of the condition of the resident,
treatment, program of care, etc.
C. New Admission—Chart on all three shifts for the first seven (7) days.
5. Document daily treatments, vital signs, etc.
6. Chart all entries legibly.
7. All entries must reflect the signature and title of the person recording the data, the date, and time.
Procedures
1. Accidents/Incidents:
Documentation pertaining to accidents or incidents involving residents should include:
a. Circumstances surrounding the accident or incident.
b. Where the accident or incident took place.
c. Date and time the accident or incident occurred.
d. Name of witnesses and their account of the accident or incident.
e. Resident’s account of the accident or incident.
f. Time the physician was notified as well as the time the physician responded.
g. The date and time family was notified and by whom.
h. The condition of the resident, including vital signs.
i. Disposition of the resident. (i.e., transferred to hospital, put to bed, etc.)
j. All pertinent observations.
k. Signature and title of person recording the data.
2. Admission Notes
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Documentation involving the admission of a resident (as they may apply) should include:
a. Date and time of admission.
b. Age, sex, race, and marital status.
c. Method or mode of admission (i.e., car, ambulance, wheelchair, etc.).
d. Person accompanying the resident.
e. Where the resident was admitted from (i.e., hospital, home, other facility).
f. Reason for admission.
g. Vital signs and condition of the resident upon admission (i.e., confused, weak, alert, etc.).
h. Time physician was notified of admission.
i. Time the physician’s orders were received and verified.
j. Description of lab work completed or time specimen was sent to the Lab.
k. Acute conditions (i.e., hemorrhaging, comatose, etc.).
l. Presence of catheter, dressings, etc.
m. Time the Dietary Department was notified of diet order.
n. Time medications were ordered from the Pharmacy.
o. Body Audit (i.e., birth marks, ostomy site, site and size of scars, rashes, bruises, pressure
signs, lesions, decubitus, burns, general cleanliness of the body, hair, nails, etc.)
p. Brief description of any disabilities (i.e., blind, deaf, hemiplegia, speech impairment,
paralysis, mobility, etc.)
q. Known allergies.
r. Prosthesis required (glasses, dentures, hearing aid, artificial limbs, eye, etc.)
s. Weight and height.
t. Statement indicating that the nursing history and assessment is completed or has been
started.
u. Signature and title of person recording the data.
3. Behavior/Orientation
Documentation of a resident’s behavior/orientation should include:
a. Any changes in the resident’s behavior.
b. The use of objective terms. Chart only the facts.
c. Description of symptoms. Avoid labels such as disoriented, depressed, etc.
d. Documentation that the resident has been evaluated for attainment of goals as well as the
progress toward attainment of the goals.
e. The goal(s) not attained by the resident. Document the possible reasons why.
f. Date and time of observation.
g. Signature and title of person recording the data.
4. Catheter Care
Documentation of catheter care should include:
a. Type of procedure performed and who performed it.
b. Date and time the procedure was performed.
c. Type and size of catheter used.
d. Necessity of catheter.
e. Resident’s response to the treatment.
f. Changes in the resident’s condition (i.e., swelling, discomfort, change in output, amount,
color, odor, any sediment, patency of the catheter, etc.)
g. Urine output. If sent to Lab and reason.
h. Any special care as well as any new problems that may have developed.
i. If the goal of the treatment has not been attained, the possible reasons.
j. Other pertinent data as necessary.
k. Date and time the procedure was discontinued.
l. Signature and title of the person recording the data.
5. Colostomy/Ileostomy Care
Documentation of colostomy/ileostomy care should include:
a. A summary of the treatment performed.
b. If irrigation is ordered, and who performed it.
c. Regular patterns of bowel elimination as established through management of diet, fluid
intake, exercise, and the use of prescribed laxatives, suppositories, and/or irrigations.
d. Irregularity, skin breakdown, or other observable conditions/concerns.
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6.
7.
8.
9.
10.
e. Nursing measures taken to assist the resident who is experiencing problems in
understanding and/or accepting the presence of colostomy/ileostomy.
f. Nursing measures taken to maintain skin integrity.
g. Documentation that indicates that the Plan of Care is being followed.
h. Problems addressed through diet changes, medication, and treatments specific to nursing
care.
i. Character and approximate amount of drainage.
j. Other pertinent observations as necessary.
k. Date and time care was given.
l. Signature and title of person recording the data.
Death of a Resident
Documentation pertaining to the death of a resident should include:
a. Pertinent information before death (i.e., symptoms, vital signs, treatment, etc.)
b. Date and time of death.
c. Name of physician notified and when notified.
d. Name and title of person pronouncing the resident dead.
e. Time family notified and by whom.
f. Name of funeral home notified and by whom.
g. Time funeral home was notified.
h. Time the resident is picked up by the funeral home.
i. When and to whom the resident is released. (Note: Alert the person receiving the
deceased resident if the resident was in isolation.)
j. Disposition of medications and personal belongings.
k. Signature and title of person recording the data.
Diabetic Urine Testing/Accucheck
Documentation of diabetic urine testing should include:
a. Type of test used and who performed it.
b. Date, time and result of the test.
c. Other pertinent observations as necessary.
d. Signature and title of person recording the data.
Discharge of a Resident
Documentation pertaining to the discharge of a resident should include:
a. Physician’s order for the discharge.
b. Date and time of discharge.
c. Reason for discharge.
d. To whom discharged.
e. Mode of transportation (i.e., car, ambulance, etc.).
f. Skin condition.
g. Summary of the resident’s overall condition. (Include ambulatory and mental status.)
h. Disposition of personal belongings.
i. Disposition of medications.
j. Family’s request to hold the room.
k. Signature and title of person recording the data.
Charting Errors
a. Do not erase any error. Erasures of any type may not be made in the medical record.
b. If an error is made while recording data in the medical record, line through the error with a
single line and correct the error.
c. Correction fluid may not be used in the correction of errors in the medical record.
d. Do not leave blank lines. Draw a single line through a blank line.
e. If the record is copied over, the nurse copying the record and the Charge Nurse must sign
in the statement to that effect.
f. All corrections or changes must be signed and dated by the person making such entries.
Follow-up Notes
Documentation relating to follow-up notes should include:
a. A summary of the resident’s condition, on all three (3) shifts, until the resident is stable.
b. Documentation that the resident’s condition has stabilized.
c. Date and time of entries.
d. Signature and title of person recording the data.
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11. Food/Fluid Intake
Documentation relating to food/fluid intake (nourishments) should include:
a. Amount of food/fluid consumed at each meal (i.e., 25%, 50%, etc.).
b. If food/fluid refused, the reason(s) why.
c. Time dietary notified and by whom.
d. Substitutions offered and the amount the resident consumed.
e. Between meal and bedtime feedings.
f. Other pertinent observations.
g. Signature and title of person recording the data.
12. Intake/Output
Documentation of intake/output should include:
a. Consistent and accurate documentation and measurement of the resident’s intake/output.
b. Each shift’s eight (8) hour total intake (i.e., oral fluids, intravenous and subcutaneous fluids,
tube feedings or levine tube instillation).
c. Each shift’s eight (8) hour total output (i.e., emesis, diarrhea, colostomy/ileostomy,
drainage, suction, urine, would drainage, etc.).
d. The 24 hour total intake/output for all three (3) shifts. (Recorded by 3rd shift at
approximately 7:00 A.M.).
e. Both intake/output documentation must be recorded when a resident has a catheter, IV,
tube feeding, etc., and whenever deemed necessary by the nurse (i.e., suspected
dehydration, elevated temperature, possible UTI, cloudy urine, etc.).
f. Documentation of the resident’s intake whenever fluids are forced or encouraged.
g. Documentation of hourly intake/output as necessary.
h. Other pertinent observations as necessary.
i. Signature and title of person recording data.
13. IV Therapy
Documentation regarding IV Therapy should include:
a. Date and time IV started.
b. Name of the person starting the IV as well as the size and type of needle used.
c. Documentation for parenteral therapy specifying the type of fluid, rate of infusion/hour, and
additives, if any.
d. Twenty-four (24) hour intake/output record.
e. Any adverse reaction to the treatment.
f. Any special care administered as a result of IV therapy (i.e., mouth care, assistance with
ADLs, etc.).
g. Documentation that reflects the condition on and any infiltrations, phlebitis, necrosis, etc.,
noted.
h. Condition of site at least every eight (8) hours.
i. Date and time of site care, tubing change, fluid change, or change of site.
j. Other pertinent observations as necessary.
k. Signature and title of person recording the data.
14. Lab Work
Documentation pertaining to lab work should include:
a. Date and time specimens were obtained. (Note: When drawing blood, document the area
from which the blood was obtained.
b. Name of resident from whom the specimen was obtained.
c. Date and time specimens forwarded to Lab.
d. Date and time results obtained.
e. Date and time physician notified of lab results.
f. Signature and title of person recording the data.
15. Leaves of Absence
Documentation pertaining to residents’ leaves of absence (i.e., trips to physician’s office,
treatments, home, emergency room, or any other therapeutic leave) should include:
a. Date and time resident left the facility.
b. Mode of transportation (i.e., car, ambulance, etc.).
c. Condition of the resident.
d. Name of person signing the resident out.
e. Reason for resident leaving the facility.
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16.
17.
18.
19.
20.
f. Date and time resident returned.
g. Condition of the resident upon return to the facility.
Medication Administration
Documentation pertaining to medication administration should include:
a. Date and time medication administered.
b. Name and strength of medication and route of administration.
c. Frequency of administration.
d. Reason(s) for prn administration and the effects of the medication on the resident.
e. Pulse and blood pressure when appropriate.
f. Reason(s) for refusal of medication. (Note: Circle and initial dosage when medication is
refused. Should the resident refuse three (3) or more doses, notify the Director of Nursing
Services.)
g. Document on the Medication Administration Record (MAR) as the medications are
administered.
h. Signature and title of person recording the data.
Oxygen Administration
Documentation pertaining to oxygen administration should include:
a. Date, time started, and time stopped.
b. Rate of flow, route, and rationale.
c. Name of the person administering the oxygen.
d. Frequency and duration of the treatment.
e. Resident’s tolerance to the treatment.
f. Reason(s) for prn administration.
g. Signature and title of person recording the data.
Refusal of Treatments
Documentation pertaining to a resident’s refusal of treatment should include:
a. Date and time treatment attempted.
b. Treatment attempted.
c. Resident’s response and reason(s) for refusal.
d. Name of person attempting to administer the treatment.
e. Documentation that the resident was informed of the purpose of the treatment and the
consequences of not receiving the care.
f. Documentation each time the resident refuses his/her treatment, the resident’s condition
and any adverse effects due to such refusal.
g. Date and time physician was notified as well as the physician’s response.
h. All pertinent observation.
i. Signature and title of person recording the data.
Restraints
Documentation pertaining to the use of restraints should include:
a. Date and time restraint ordered and name and title of person ordering the restraint.
b. Type of restraint.
c. Reason(s) for the use of the restraint and the resident’s response.
d. Documentation that the resident’s restraint is released every two (2) hours for ten (10)
minutes.
e. All pertinent observations.
f. Signature and title of person recording the data.
Skin Lesions
Documentation pertaining to skin lesions (i.e., decubitus ulcers, abrasions, etc.) should include:
a. Specific location of the skin care problem.
b. Number, size, degree, and measurement of decubitus ulcers.
c. Documentation that skin surfaces are looked at regularly for the resident at risk or residents
exhibiting any rash, irritation, or other skin problem.
d. Regular observations of skin surfaces that touch each other (i.e., prominences, etc.).
e. Clear indication of contributing factors to the development of the skin condition. (i.e.,
inactive, incontinent, undernourished, etc.)
f. Documentation of the cause of decubitus ulcers developed in-house, as well as
substantiation of preventing interventions.
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21.
22.
23.
24.
25.
g. Documentation of turning and positioning schedules to prevent undue pressure, decubitus
ulcers,etc.
h. Any changes in the resident’s condition or response to treatment.
i. Dates of occurrences of a skin problem or pressure sore as well as the date the problem
was solved.
j. Progress, deterioration, or the development of new problems.
k. Use of special creams, lotions, medications, or protective devices.
l. The cause of any bruise or wound.
m. Consultation from other disciplines.
n. Other pertinent observations.
o. Signature and title of person recording the data.
Special Observations and Monitoring
Documentation pertaining to special observations and monitoring should include:
a. Date and time observation made.
b. Name of person reporting the observation.
c. Any expected side effects.
d. Effects of any new medications or treatments.
e. Any observation ordered, as well as the length of time the observation was ordered.
f. All pertinent observations.
g. Signature and title of person recording the data.
Suctioning
Documentation pertaining to suctioning should include:
a. Date and time resident was suctioned.
b. Name of person performing the procedure.
c. Frequency of suctioning and reason(s).
d. Any special treatment the resident received in conjunction with suctioning (i.e., oral
hygiene, skin care, replacing equipment, etc.)
e. Description of the material suctioned (i.e., amount of sputum, color, consistency, any
bloody aspirant, cardiac arrhythmia, cyanosis, etc.).
f. Resident tolerance before, during, and after the procedure.
g. Route of suctioning (i.e., oral, nasal, trach).
h. Any progress or lack of progress, deterioration, and/or the development of new problems.
i. All pertinent observations.
j. Signature and title of person recording the data.
Transfer (Room to Room, Hospital, ECF)
Documentation pertaining to the transfer of a resident should include:
a. Date and time the transfer was made.
b. Reason(s) for the transfer.
c. Date and time family notified and by whom.
d. Location of the transfer (i.e., hospital, ECF, new room #, etc.).
e. Mode of transfer.
f. Resident’s response to the transfer.
g. All pertinent observations.
h. Signature and title of person recording the data.
Treatments
Documentation pertaining to treatments should include:
a. Date and time each treatment administered.
b. Name of person administering the treatment.
c. Specific duties performed.
d. Reason(s) for a resident’s refusal of the treatment.
e. Signature and title of person recording the data.
Tube Feedings
Documentation pertaining to tube feedings should include:
a. Documentation that proper tube placement is verified prior to each feeding.
b. Time each feeding was made.
c. Name and title of person performing the procedure.
d. Accurate intake and output data.
e. Resident’s tolerance to the tube feeding.
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f. Any removal and reinsertion of the tubes.
g. Frequency, amount and number of calories.
h. Any problems of limitations as a result of the tube feeding.
i. All pertinent observations.
j. Signature and title of person recording the data.
26. Vital Signs
Documentation pertaining to vital signs should include:
a. Date and time vital signs taken.
b. Any deviations from the resident’s normal pattern (i.e., weak, rapid pulse, etc.).
c. Refer to item #10 for follow-up procedures.
d. Date and time physician notified as well as the physician’s response (as applicable).
e. All pertinent observations.
f. Signature and title of person recording the data.
27. Weights:
Documentation pertaining to weights should include:
a. Date and time weight obtained.
b. Name of person obtaining the weight.
c. Weight variations as they occur.
d. Reason(s) for weight variation (if known).
e. Date and time physician notified of weight variations as well as the physician's response.
f. What is to be or is being done.
g. All pertinent observations.
h. Signature and title of person recording data.
28. Miscellaneous Documentation
Documentation should also include:
a. Any time the physician or family is called about the resident as well as their response.
b. Each time a physician visits the resident.
c. Whenever appointments are cancelled, rescheduled, and missed. Document the reason(s).
d. Whenever the level of care changes.
e. Whenever a bed/room change is made.
f. Whenever prn medications are given as well as the reason for such medications. (Note:
Document any side effects of the medications.)
Nursing Summaries and/or Assessments
When charting nursing summaries, or making assessments, include (as they may apply) the following data
for:
1. Ambulation Status:
Mode, amount and type of assistance needed, tolerance level, and transferring capabilities. (i.e.,
Bedfast, bed to chair, walks with or without assistance, uses wheelchair or walker, how long up,
etc.)
2. Activities:
Discuss the resident’s participation and his or her input. Discuss whether or not the resident
participates in lone or group activities.
3. Bowel and Bladder Training:
Specify the level of continency, any problems, type catheter, any bowel problems, progress,
deterioration, and status of the bowel and bladder training.
4. Care Plans:
Reflect the effectiveness of each part of the care plan and the status of the goals.
5. Contractures:
Describe the location, degree, and treatment administered (if any).
6. Communication:
Describe the resident’s method of communication. (i.e., verbal, non-verbal, response to stimulation,
ability to make needs known, etc.)
7. Exercise:
Describe the types of exercise (range of motion). Is it active or passive? Is it performed alone or in
group therapy?
8. Impairments:
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Describe any impairments in the resident’s speech, hearing, or sight.
9. Management/Behavior:
Describe any problem(s) noted during the month and the frequency of such problem(s). Indicate if
the resident was belligerent, friendly, cooperative, etc.
10. Medications:
Summarize the use of prn’s with reason, effects, and frequency of use. Discuss the effects of new
medications/dosage changes as well as medications that require monitoring or observation.
11. Mental Status:
Describe the resident’s orientation and any programs used (i.e., Reality Orientation). Indicate if the
resident was confused, disoriented, alert, lethargic, restless, weak, fatigued, semi-comatose,
comatose, etc.
12. Nutritional Status:
Document the diet, appetite, food consumption, eating habits, assistance needed and where, diet
normally consumed, weight variations, hydration status, fluid intake, tolerance of tube feeding, etc.
13. Oral Hygiene:
Describe the teeth, gums, and tongue.
14. Personal Care:
Refers to activities of daily living (ADL)—dressing, bathing, grooming, oral hygiene; assistance
needed, etc. describe the type and amount as well as self-care.
15. Restorative/Rehabilitative Programs:
Summarize nursing rehabilitation programs and progress. Note PT, OT, and ST attempted,
progress, and frequency.
16. Restraints:
Indicate the type of restraint used, when it was applied and released, the duration of the restraint
use, and the purpose of the restraint.
17. Seizures:
Document last seizure, type, frequency, length of, and any other special information.
18. Skin—Hair—Scalp—Nails:
Dry, moist, scaly, etc. Be descriptive of lesions, edema; discuss locations, size, depth, color,
amount, consistency, odor of drainage, and status of tissue and surrounding. Indicate type of
treatment and how often treatment is administered.
19. Toilet Habits:
Catheter, incontinent of the bowels and bladder, chronic constipation, laxative (routine or prn).
20. Unusual Occurrence/Significant Incidents:
Pick up on conditions of past month. Indicate whether improved or worsened. (i.e., Decubitus, UTI,
cold symptoms, refusal of medications, treatments, food, bath, activities, etc.)
21. Visits:
Indicate whether or not the resident’s physician and family members visited during the month.
22. Vital Signs:
Indicate whether or not the resident’s vital signs were fluctuating, elevated, or stable.
Physician Orders
The following information is provided to assist you in recording physicians’ orders.
1. Supervision of a Physician:
a. Each resident must be under the care of a licensed physician authorized to practice
medicine in this state and must be seen by the physician at least every sixty (60) days.
b. Physicians’ orders must be signed by the physician and dated when such order was
signed.
c. Current lists of orders must be maintained in the clinical record of each resident and are
necessary to avoid confusion and errors.
d. Orders must be written and maintained in chronological order.
e. Physician orders must be reviewed and renewed;
f. Every 30 days for SNF residents. (Note: This may be changed to every 60 days after the
first 90 days of the resident’s admission, provided it is approved by the attending
physician.)
g. Every 90 days for ICF residents.
2. Content of Orders:
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a. Medication Orders:
Specify the type, route, dosage, frequency, and strength of the medication ordered (i.e.,
Dilantin 100 mg po TID). A placebo is a medication and must also have specific orders.
b. PRN Medication Orders:
Specify the type, route, dosage, frequency, strength, and the reason for administration (i.e.,
Tylenol gr x po prn mild pain or temp = 101°.)
c. Oxygen Orders:
Specify the rate of flow, route, and rationale (i.e., 2-3 L/min per nasal cannula prn SOB).
d. Nasogastric Tube:
Specify the type of feeding, amount, frequency of feeding, frequency for tube change, and
rationale if prn. Should always be followed by water. (i.e., Nt if refuses po intake 48 hours—
give Isocal 250cc and H2O 50cc q 4 hours.)
e. IV Orders:
Specify the type solution, rate of flow, and volume to be infused (i.e., 1000cc D 5W IV @
50cc/hr. DC when infused.)
f. Restraint Orders:
Specify the type, reason, frequency of check and release, duration of use, and purpose of
restraint.
g. Treatment Orders:
Specify what is to be done, location and frequency, and duration of the treatment (i.e.,
Betadine and sugar to sacral ulcer q shift until healed).
h. Commercial Supplements:
Specify the type, amount, and frequency (i.e., Ensure 3 oz. TID between meals).
i. Foley Catheter:
i. If prn, specify why it is needed.
ii. Irrigation—Specify type, amount, frequency, and reason (i.e., irrigate with 50cc NS
for clogging 2° sediment q 8° prn).
iii. Specify the size (i.e., #18 Fr foley cath to straight drain) and the frequency of
change.
iv. Catheter care—Specify what is to be used or “according to facility procedure”.
v. Physician orders are needed for LOA’s; PT, ST, and OT evaluations and therapy;
consultation from other physicians, diet, activity, X-ray, labwork, transfers,
discharges, etc. Therapy orders are to be renewed every 30 days, which may be
recorded on therapy notes.
3. Telephone/Verbal Orders:
a. Telephone/verbal orders may be accepted from a licensed physician or dentist only by a
licensed nurse.
b. Such orders must be countersigned by the issuing physician/dentist within forty-eight (48)
hours after issuing the order.
4. Standing Order:
a. Standing orders should be recorded as a telephone order. Record on the order sheet.
b. Sign as follows:
i. “Standing Order, Dr._________/ your name and title”.
5. Automatic Stop Order:
a. Utilize the same procedure as with telephone and standing order. Sign as follows:
i. “Automatic Stop Order/your name and title”.
b. Never just “drop” an order. Always write an order to discontinue any order.
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