RE: Questions and More Questions

[k.karren]

Ditto here    and                         3.  we chart only if something out of the ordinary happens and also complete a monthly summary.   -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of [EMAIL PROTECTED] Sent: Friday, January 16, 2004 10:33 AM To: [EMAIL PROTECTED] Subject: Re: Questions and More Questions   Here are some answers for all those questions 1.yes- on our mars it has both names of the medication, diagnosis and date original order was written, plus the initials of the nurse transcribing the original order or the nurse who is writting the new monthly mars. 2.  Our tars do not show the stage of the wound we have a weekly wound tracker that the care manager keeps and makes the weekly entries with measurements etc- so nothing on the tar. As far as nurses documenting our nurses document daily on the wound in regards to s/s of infection, drainage etc-just not measurements unless they are the one who did the weekly measurement for the care manager and then they will document the measurements. 3.I work sub-acute so I do not know the requirements for LTC.   Hope some of this is helpful.  I think that each facility should have a policy and procedure book that should state what is expected and the frequency.  At least that is what I have encountered in the 3 states I have worked in. Lisa       In a message dated 1/16/2004 8:01:17 AM Mountain Standard Time, [EMAIL PROTECTED] writes: Hello talkers, I'm looking for feedback on some basic questions. If you can point me in the direction of anything written to support any of this, I'd appreciate it. Do you have both the generic and brand name with a diagnosis for each med appear on your medication administration record and on the physicians order for medication? Does the date of the original order appear on the medication administration record every month it's carried over? Do your new orders include these? Do your treatment administration records show the stage, if applicable, of the wound being treated, as well as measurements, description, location? What kind of documentation do you do for wounds of all kinds? With your stable long term care residents, who have no changes for months at a time, how often do the nurses write a nurses note? Thanks in advance to all who respond, Dorothy Dorothy Wolfe, BSN, MDS Coordinator The Virginia Home 1201 Hampton St. Richmond, VA 23220 804-359-4093