Monthly progress notes on dialysis patients

Trauma Columnist · Oct 12, 2006

Hmmm...I am a dialysis advanced practice nurse in a huge practice. Our RN's don't do monthly progress notes...just the day to day charting. However, Medicare reimburses for four medical visits per month (as long as the pt is seen on HD). One of these four must be from an MD, while the other three can be from an APN or PA.

I work at two large Fresenius facilities and that company doesn't require montly notes from the RN's. There is a care-plan though that is required quarterly, but is multi-disciplinary.

DeLana_RN, BSN, RN · Oct 12, 2006

At my large national for-profit company, all RNs and LPNs were supposed to do monthly progress notes on their primary patients (10-15 patients, depending on census and staffing). Mandated were 5 entries for each patient (I added some sample notes to give you an idea):

- anemia management

Hgb x. EPO increased to x U qtx. Venofer x q wk.

- adequacy (was Kt/V reached; if not, reasons)

Kt/V inadequate at 1.10, however this is unusual for this pt. He missed tx 3 times this month due to personal problems; tx compliance encouraged.

- access (type, problems)

CVC removed on 9/25; new AVG with strong thrill and bruit, easy to cannulate.

- HTN (meds, compliance)

Most recent post-tx BPs [below x/x or list them]; current meds: ...

- Weight (dry weight changes, avg intradialytic gain)

EDW increased to x kg; avg wt gain 2.0 kg.

Those were the mandated ones - plus we could add anything we wanted to from a long list (yeah, right :lol2: )

In order to do these progress notes, you needed to print certain reports, which had to be up-to-date. Need I add that the daily workload of a clinic nurse simply did not allow for all of this to be done?! (Yes, management wanted us to do this in our spare time - and I don't mean OT, oh, no, within 40! :uhoh3: )*

If they could, they would give you a "paper day" - about the only way this could be done; of course, due to staffing problems, these were usually cancelled. So you were constantly behind (you could never possibly be caught up - if you were, the next month would come around...) It was a constant source of stress for those of us (only one other nurse besides me) who tried to do it - the rest simply didn't, or only if given the extra day. But since we were all behind on the notes (more or less), management could us this as a tool to downrate us during review time :madface:

*This in addition to monthly med checks on these same patients (asking them to bring in their meds, address any problems with the neph, update the list in the computer) and monthly footchecks on all assigned patients (these used to be weekly! :uhoh3: ), which had to be documented in the computer.

Sorry, I wasn't trying to scare you (I guess this was a belated vent on my part ). This was one clinic, one manager, some time ago.

To tell you the truth, I loved my paper days; they were a nice break from the floor, and let me sleep in. If your manager will let you have those, take you off the floor during slower periods, or let you work OT (if you care to), progress notes should not be a source of stress. They're the same thing that the SW and dietician have to do monthly (but of course they have the time :rolleyes: )

HTH. Best wishes to you!

DeLana :)

kdhnursern · Oct 13, 2006

As a clinic which has recently gone from one owner to another one, we are just learning what the requirements are. We were doing monthly short term care plans (multidisciplines) and we had done nursing progress notes that we had a template to fill out like the STCPs. It seems that someone is always coming up with more paperwork for us. But with 25 patients, 8 chairs, 6 days/week, and 2 RNs (one 40hr/wk, 1 30hr/wk) plus our RN facility manager, and 3 PCTs who like to have RNs help with the technical work load so they can leave early ("nurses can do their work after we leave, they want the hours"), we have a hard time getting our paperwork done. Our facility manager takes 1/3 of the patients to do CPs/NPN/med lists/etc on but she has her hands full with supply ordering, the new lab ordering, keeping up with HER paperwork, etc. In our "slow times", the other RN and I attempt to get paperwork done. But what with the PCTs leaving the clinic area to get their work done way early (no, the bicarb doesn't have to be mixed and poured before the patients leave) and one that likes to go to the restroom 20 times a day (with her cell phone so she can text-message her boyfriend/friends) and another PCT who can disappear when patients need something or are ending their txs and uses clinic time to get HER ordering done so she can leave after the patients are gone(she's the one who says the nurses can do their work after the PCTs leave) , the RNs end up keeping the updating done and catching the alarms because we're the only ones left on the floor.

Okay, that was MY rant of the week. The other RN and I have talked about this endlessly and can see no "light at the end of the tunnel".

As you can see, though, paperwork is time consuming and there just doesn't ever seem to be enough of that time available. We piece it in wherever we can. I keep to-do lists to keep myself up to date. Sticky notes everywhere!

We are constantly trying to get it more organized. :banghead:

Good luck with yours!

DeLana_RN, BSN, RN · Oct 13, 2006

Kdnursern,

oh the joy of clinic nursing :uhoh21: - I remember those days too well. Just to keep up with all the paperwork I was supposed to do, I had made up a worksheet on my home computer with my primary patients' names (up to 15 at a time!) and columns for med check (date requested/done), PN, misc. I stapled that to the reports (yes, I was that dedicated - took work home, unpaid of course - what a fool I was, it never got appreciated :smackingf ). My coworkers - nurses and PCTs who during the spent the slower times surfing the 'net, using their (forbidden) cell phones on the floor, or dozing at the desk - just rolled their eyes at that... :mad:

Actually, the company I worked for wasn't too bad - until about a year before the merger. Then it started becoming lean and mean; the new RD, a s---- b---- from h--- (no exaggeration, sadly), started nickling and diming us to death. Now, for instance, an employee (nurse or PCT) had to be sent home whenever patient census dropped below a specified number; due to poor and weak "leadership" (charge nurse and unit admin), this was determined with no regard to patient acuity or fairness. For instance, total census after turnover dropped below the dreaded number, as it usually did on TTS; Team A had 9 patients on, Team B 7. A PCT or LPN from Team A - with a full section of 4 patients - would now scramble to go home, which was approved, leaving the RN and other team member to take off all 9 patients. Help from Team B? Forget about it. Again, poor leadership.

Sorry about that belated rant :rolleyes: My point is just, under such circumstances you were supposed to do paperwork - in your spare time?! RNs were now doing more work that could have been done by PCTs or even reuse techs, and this was cost effective?! Sometimes you wonder what planet some of these upper level managers are from :jester:

DeLana :)

KidneyCleaner · Oct 18, 2006

I work for a huge dialysis company that has clinics all over the US. We do monthly progress notes. If a pt comes in with a fever & ends up getting antibiotics & you chart that...THAT is the monthly note. If you have a pt that evrything goes well most of the time your monthly note may look like this:

Pt arrived at HD as usual & without c/o. SBP up at 198 but comes down during dialysis. Fluid wt gains range between 2.5-3.5 kg/tx. No other complications noted. Pt does miss a tx on occasion.

Hope this helps ! :)

Migrant_Renal_RN · Oct 27, 2006

i think that you have all been hiding out in my clinics. i am a clinical nurse manager, the company i am w/changed hands a yr ago, i had only been in the company for 6 months, and was already in my second clinic; i am now in a 3rd. all 3 of these are within the same region. paperwork is really a 4 letter word, i am not sure what the other 5 letters are doing there:lol2: !! our monthly progress notes?@!#, omg!!! i have been at my current clinic for 6 months. i have had 6 different rns in that time, 2 are still w/me, but 1 has been out on maternity leave since hurricane ernesto:uhoh3: ... i cannot even begin to tell you how far behind i am....:monkeydance:

i was just recently informed that it is no longer necessary for us to write a formal monthly note, as long as we are making per tx incidental notes, as things occur. best of luck!! look forward to reading further submissions.

DeLana_RN, BSN, RN · Oct 27, 2006

That's great! We actually had to do these incidental notes in addition to the "official" progress notes, most of which were really unnecessary because all of the info could easily be derived from labs (actually, anemia management was finally computerized and we no longer had to do it), nephrologist's progress notes, and short and long term care plans.

This should make your life - and your nurses' - much easier. Now they can get to those med and foot checks

DeLana

mmurphy · Nov 6, 2006

I believe you must be mistaken. In every state it is a CMS regulation that an RN must do a minimum of a monthly progress note on each patient in the chronic dialysis census. These notes must address: pt. access, hospitalizations, infections, compliance with treatments, average fluid gains, etc. Maybe you are not aware of the variety of duties that staff RN's in a dialysis facilities perfrom.

Hmmm...I am a dialysis advanced practice nurse in a huge practice. Our RN's don't do monthly progress notes...just the day to day charting. However, Medicare reimburses for four medical visits per month (as long as the pt is seen on HD). One of these four must be from an MD, while the other three can be from an APN or PA.
I work at two large Fresenius facilities and that company doesn't require montly notes from the RN's. There is a care-plan though that is required quarterly, but is multi-disciplinary.

SuperStarRN · Oct 1, 2011

I keep seeing "RN" but I am an LPN who has been in dialysis for only 5 months and was recently given the task of doing half of the monthly progress notes for our facility. MY charge nurse has the option to take a couple of hours and go in her office to complete hers while I have to fight to get them done in addition to running the floor while my techs take personal phone calls and pull "disappearing" acts for hours at a time much like all of you describe. Did I mention the 30 minute lunch breaks that usually take them at least an hour? I can barely find the time to get my day-to-day duties on the floor done let alone progress notes. I have resolved to bring them home and complete them only because I know I have to get them done. So annoying and not to mention wrong on every level!