“Whenever I think of something but can't think of what it was I was thinking of, I can't stop thinking until I think I'm thinking of it again. I think I think too much.”
_{Criss Jami, Killosophy}

Certainly this resounds with sense and most of our current thought processes when writingany documentation evidencing resident care. Maintaining a balance to evidencethe usual or assessed need, resident preferences for their care, and then theworst level of care required and when it is delivered is a new skill requiredof RNs, Managers and AN ACC specialists.

Throw intothe mix any new wording about to be released with our new Quality Standards then we need to go back to school on how to write a nursing note. What is iteven all about?

It iseasier then you think. Keeping it simple, write a story about the resident.Write about what you saw, what you assess as needed, how did the resident respond to that care, How would the resident like the care to be delivered? Andlastly, when the resident is sick / fatigued / confused or any other issue that impacts their normal functioning,how is care then delivered?

Get in touch if you need more support or would like further training in your facility