Re: ?Regulation re Shift Change MAR Review

[Delores234]

OK, lets think about this--nurses are responsible for documenting on the MAR.  Nurses give report between each shift--right?  I hope so.  Any blanks on the MAR or TAR should be reported in
             1. The change of shift report and
              2. Prominently listed on the 24 hour written report.-- you do this
                   right?  I hope so.

In fact it should be written in red on the 24 hour written report.  Label companies have a very useful label for the 24 hour report.  It is tiny, about one inch, comes in fluorescent red and all it says is "Follow-up".  I encourage clients to use it whenever an entry on the  24 hour report needs further action.  Example: call to physician at 3pm who has not called back.  Or charting that has not been done.

Delores

Good luck Holly!  I have attempted to implement such a process, with some success, but it is very difficult and energy consuming to change culture.  One of our two deficiencies last year was documentation on an MAR, and after all the education, quality monitors, policy revisions and so on, I found someone last week taking the same shortcuts that caused the deficiency.  Culture change is possible, we have accomplished quite a bit here, but it is certainly a challenge! 

Mary Jayne

Delores L. Galias, RN, RHIT

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