experience –
charting at night hellllpRating: (votes: 0) ex- "Pt rec in bed with eyes closed. Arouses easily to verbal stimuli. Respirations even and unlabored. Skin warm, dry, and intact. Offers no c/o pain or discomfort at the time. Safety measures in place. Call bell in reach. Will cont to monitor." This was an issue I had as well working nights in LTC. I basically charted similiar to your example. Comment:
Sounds good except the "will continue to monitor".. What are you monitoring? See a lawyer can take that as a problem. The only time I chart will continue to monitor is IF there is a problem, then I also chart my interventions, VS etc through out the night.
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