Need Help Charting

[LTC LPN 2006]

I'm new and not very good at charting. I've tried to pick up some of the lingo/phrases other nurses use in their charting but could use advise/tips on things I may be forgetting to include. I currently work 3rd shift in a nursing home and many of the residents do not have much to chart on at night. My typical charting for someone who slept the whole night might be:

"Resident slept quietly in bed all night. No c/o pain or discomfort. No SOB. VSS. Call light within reach. ------------------"

It is much easier to chart when there was more involved in their care... but since this is their home sometimes there are a few nights in a row that are uneventful but that I'm still required to chart on them due to them being on medicare or something. Any suggestions on ways to change my charting, things I should be including or shouldn't include? I hate for my charting to appear the same day after day and have it look like I just write the same thing over and over.

Thanks!

[cougarnurse]

Let's see....Are the VS recorded? Of course....mention skin warm/cool/dry/etc. Continent? Assisted to BR? If so, how are they walking? It's been a while since I did medicare charting, but I will remember more later!

'Cat'