[nursefifi]

I have a question about travel charts. Is it the norm in Home Health to have a chart to carry on each visit which contains the 485, med list, labs, prior visit notes and any other pertinent information? I previously we worked for a hospital based home health and these were provided and kept very up to date. I have been working for a month for a very large home health and so far have not had any of this information. I am lucky to have a 485 with me. I work part time and paid per visit. I am finding this very challenging! I do not know what the patient has been taught, what the prior labs were, or what the previous nurse did while in the home. I have only been there 1 month and hate to rock the boat! I feel this information is necessary for continuity of care. I still work prn for the other agency on some weekends and am seriously considering going back part time because of this. Just wanted to know what the protocol is for other agencies. I would appreciate your feedback. Thanks.

[caliotter3]

At the agencies I have worked for, the field chart was kept in a binder in the home and contained many things. These were as complete, up to date, and organized as the assigned nurses put forth the effort to keep them that way. I was always complimented on keeping the books together b/c I would do this stuff on noc shift. One of the agencies, as part of its "book" had a sheet which described what would be in the field chart as a minimum. Before I even went on a case, I would get a copy of the 485, the current med sheets, and any oral orientation from the supvrs in the ofc before I went on my first visit. I also would go on a formal orientation visit the first visit. If this agency that you are describing does not already establish and maintain field charts on its clients, I would not take it upon myself, if I were you, to try to invent Rome. You either will meet with resistance, total disapproval, and a lack of cooperation, or a positive response. This is too much of an endeavor for one person to take on without administrative assistance from the office staff. You say this is a very large agency, chances of anything positive are nil. Too much headache. Even if you offered to do it for just the one case you are working on. Frankly, I don't see how you are expected to accomplish quality care with these conditions. Paperwork ain't fun, but it is necessary, particularly when you do not relieve or are relieved by nurses that you can get report from.

[Cattitude]

Originally Posted by nursefifi

I have a question about travel charts. Is it the norm in Home Health to have a chart to carry on each visit which contains the 485, med list, labs, prior visit notes and any other pertinent information? I previously we worked for a hospital based home health and these were provided and kept very up to date. I have been working for a month for a very large home health and so far have not had any of this information. I am lucky to have a 485 with me. I work part time and paid per visit. I am finding this very challenging! I do not know what the patient has been taught, what the prior labs were, or what the previous nurse did while in the home. I have only been there 1 month and hate to rock the boat! I feel this information is necessary for continuity of care. I still work prn for the other agency on some weekends and am seriously considering going back part time because of this. Just wanted to know what the protocol is for other agencies. I would appreciate your feedback. Thanks.

We used to have them before we went to laptops. Now all the info can be found right there. All our disciplines chart there as well so I can easily pull up PT or Social Work's note too.
Also, in the home we keep a binder with a current list of meds as well as info for the pt. and some blank sheets for the RN (we send consults to MD's) It's a pretty good system.
Our per diem nurses don't have laptops of course but always get copies of 485's, med. list, wound care if ordered, any other pertinent info.