Available on Amazon.com and Kindle
Charting in a nursing home is a very, very important part of being a Social Worker. "If it wasn't charted, it wasn't done." This is an understatement, at best. State and Federal examiners go over charts with a fine tooth comb. The years I worked in Social Work, our department never had any 'dings' or marks from the examiners. If you do it right, each week, it pays off.
Example of someone needing psych evaluations is a good one. You will not get a psychiatrist to come to a nursing home, unless you have super rich residents, simply because it boils down to not enough money can be made for a psychiatrist to visit there. Most all nursing homes have contracts with psych services and psychologists are the ones who visit. Now they can give a recommendation as to whether a person may need a psychiatrist, but you have to send them out to a psyche hospital for that.
Example of charting: Alice (call the person by name, examiners like the personal touch), was crying today, again. She has been tearful for several days now. When asked, by staff, what is wrong, she cannot give a concrete answer to that question. Alice hangs her head when talking, not looking Social Worker in the eyes. (Even chart if she wrings her hands, has unsteady speech or anything else you might observe in her manner.) The psych paper from Social Services was made out (questions you ask to help evaluate if they need services) and Alice's answers indicate if a psych evaluation is in order. Social Services requested from the nurse to ask her doctor for an order for the psychologist to visit and give staff a written evaluation to see if we need to pursue any further actions. More charting on this will be done after the psychologist visits.
Now, saying more charting will come, means you Have to chart more after the psychologist visits. The psychologist will ask each time they visit, for a list of who they need to see. Keep a good list for them.
In a more minor charting situation, such as maybe you want to check on a resident weekly, but may or may not have time, Do Not say you will do that. If you Say you will do that, you Have to do it in order to satisfy the examiners.
Example of Alice needing psych help in a facility: The psychologist recommended Alice have a more intense evaluation in a psychiatric facility. Social Services has requested from nurse to notify her doctor to write an order so we can send her to a facility for more help.
Then when you transfer Alice, you make out the proper paperwork for the hospital to admit her and chart that as well. When the Social Worker from the psych hospital calls you, she will tell you what was done, and if changes were made to Alice's medications. When you get off the phone, chart what that Social Worker told you. Then when Alice returns, chart what her written orders say as well.
I hope this gives you some help in how to chart. If it looks like you are writing a book, good, because the more pertinent details you can include, the more examiners will figure you are doing your job. Happy Social Work.