State surveyors say we must document case conference notes on all clients. Case conference is to be between the Supervisor and the Primary Nurse. Notes are to include status, any new problems, changes, etc. My question is how do you document these case conference notes in other agencies? So I'll tell you I am a Supervisor and will not ask my nurses to do one more piece of paperwork. We discuss cases all the time but rarely document in the chart..now we will!
Aug 19, '03
by NRSKarenRN, BSN, RN Moderator
Case Conference was a BIG problem at my agency 2 years ago til we came up with a 1 page flowsheet note which the Clinical Managers/supervisors complete.
Label the top " Case Conference"
Left side lists names of services+ we fill in who we spoke with:
Right side of form lists major discussion topics with check off areas
___ Admission report. Primary DX:_________________
___ Additional services needed____________________
___ Home/ CG problems noted____________________________
___ Wound care reviewed and appropriate for Stage_____.
Supplies obtained from _________________________
___ Therapy reviewed. Goals _______________________
___ Visit rescheduled due to
___ doctors appointment
___ outpt test
____ patient not available
____ agency/case management need : patient notified
____ lack of insurance authorization/approval
___ Patient hosptialized at _____________ due to ________________
___ Hospital Discharge planing/case management notice sent
___ Discharge planning initiated
Tenative discharge date______________
__________________________________________________ __________________________________________________ ____
This got us through state survey and JCAHO !
Last edit by NRSKarenRN on Aug 19, '03