Doris M. Burke

Resident alert and oriented x3, pleasant and cooperative. Surgical incision left hip clean, dry, intact, staples in place, no drainage or odor. New stage 1 pressure area right heel — offloading boot applied, turn schedule tightened to q2h, wound nurse consult requested. Ate 50–80% of meals, fluids encouraged. Participated fully in PT and ST. Refused 14:00 PRN oxycodone. No falls. Call light within reach at end of shift.

POD 12 s/p left hip ORIF. Weight-bearing as tolerated continued. Lungs clear, no lower-extremity edema today. A1c pending. Continue apixaban through 9/6. New heel pressure area — agree with offloading and wound consult. Anticipate discharge readiness evaluation at day 21 pending therapy progress.

All scheduled evening medications administered. Blood glucose 142 at bedtime. Resident settled, denies pain. Bed in low position, alarm pad active.

Met with resident and daughter by phone. Discussed benefit day count (18 of 21 used) and the appeal process if Medicare coverage ends before therapy goals are met. Home assessment scheduled. Daughter requested grab bars and a bedside commode be added to the DME list.

Who can chart where

• · CNAs chart care tasks: turns, meals, hygiene, intake and output, behavior.
• · LVNs chart medication passes, treatments, blood sugars and vitals.
• · RNs chart assessments, wounds, changes of condition and physician notifications.
• · Physicians and NPs write orders and progress notes.
• · Therapy, dietary, social services and activities each have their own note type.
• · Nothing is ever deleted. A correction posts as an addendum with a new timestamp.