I make a patient problem list including the expected
documentation and stick it as page one in the nursing notes. You yellow
out or add as needed. I think problem lists are the best thing on the
planet for many SNF.
Yes, that is what our social services does, and I
take it a step farther, and also doccument what the social services person
said and what was said during my interview with the staff in the care plan
notes.
for example, for mood & behavior...nurses
have not documented resident fears and delusions, but when staff are
interviewed they say 'oh yes, she has talked about the little boy
drowning, or falling out of the window, or the fire, etc.'. It is
such a common occurrence for her that they seem to just expect it
from her (we do have it careplanned). Would social services (who
enters this section) be justified in documenting her conversations with
staff and entering on MDS even though it is not documented during the
observation period in the nurses' notes, even though her conversations
with other staff occurs after the obs. period (or does this even
matter?). Ifpossible, please reply today since we have care plan
meeting this afternoon. (& thanks again).
Kathy Archibald RN Living Center
Supervisor Caribou Memorial Hospital email: [EMAIL PROTECTED] FAX
1-208-547-2790 Soda Springs ID
83246
