Skilled Nursing Charting Checklist
Skilled Nursing Charting Checklist
General Items
- Ensure all charting is completed in a timely manner
- Use clear and concise language
- Maintain patient confidentiality
- Review and sign all entries
- Ensure compliance with facility policies and regulations
Patient Information
- Verify patient's full name
- Confirm patient ID number
- Document date of birth
- Record admission date
- Include primary diagnosis
- List secondary diagnoses
Vital Signs Monitoring
- Record temperature
- Document pulse rate
- Log respiratory rate
- Measure blood pressure
- Assess pain level
Medication Administration
- List all medications administered
- Note dosage and route
- Document time of administration
- Record any patient reactions
- Verify allergies
Nursing Assessments
- Conduct head-to-toe assessment
- Document skin condition and integrity
- Assess mobility and range of motion
- Evaluate mental status
- Record nutritional status
Care Plan Updates
- Review current care plan
- Document any changes in patient condition
- Update goals as necessary
- Record interventions completed
- Evaluate effectiveness of interventions
Patient Education
- Document education provided to patient
- Include topics discussed
- Note patient understanding and feedback
- Record any materials given to patient
- Schedule follow-up education session
Discharge Planning
- Assess readiness for discharge
- Document discharge instructions given
- Record follow-up appointments made
- Include home care needs
- Ensure patient understands discharge plan
Generated from Panda Checklist
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