paperwork paperwork ;-)

  1. The deluge of paperwork demanding my attention is sometimes overwhelming. Insurance referrals top the list of time thiefs but I also spend a great deal of time documenting phone calls and patient education.
    Does anyone have any standard forms they use for Pt.ed? Are there any source book or text books that attend to the matter of recommendations for office documentation?
    Thank you for your input!! Email me at Darlazaon@aol.com
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  2. 1 Comments

  3. by   Jo_deye_yuh
    Darla,

    I am not sure if this is exactly what you are looking for but, we created a med refill sheet that goes in the front of the chart under the pt info sheet. Instead of documenting the whole event of pt calling in req a RF and the med, sig, and # of RF and to what Pharm and what Dr ordered it, etc.

    The form is on thick paper and is gridded with spaces lined out for date, med, sig, # of RF, Pharm, Dr ordering, and nurse initials.

    EX:
    1-23-00 \Lasix \40mg i po qd\ #30-1RF\RML\JB

    This saves time and chart space. If additional info needs to be written such as, "pt needs labs and FU" can be written below that RF.

    However, the time consuming documentation of phone calls and walk-in tx per nurse, I wish I had the answer to that one!

    As for pt ed, I use Kraisers pt ed/teaching/info brochere's, and do my own research and put together pertinent info that applies to what we do and want our patients to know/do/don't. I type up cast care info from several resourses and credit those sourses at the end of the info.

    I have created many forms that pertained originally to my dr in the clinic, but other drs liked how streamlined they were and wanted to use them too. So back to the printer they went to apply to the whole clinic's use. Diagnostic forms, work release forms, and pre-op pt info forms etc.

    As an oxymoron as it is, I created new forms to get rid of the bulk of paperwork that just meant doing the same documentation over and over. One form for RF's helped a lot. One form for another specific area cuts corners, as long as that form is as specific as can be.

    Hope I offered a tid bit of ideas.

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