- 0Aug 18, '03 by amesly15State 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!
- 9,364 Visits
- 0Aug 18, '03 by KP RNOur agency does not require case conferences, per se. However, we do document interdisciplinary communication at least every fourteen days. Our skilled nursing visit notes have a line which is for IDC, we simply write the name and the discipline of the person we communicated and what was discussed.
- 0Aug 19, '03 by NRSKarenRN AdminCase 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
- 0Aug 19, '03 by amesly15Thank you so much Karen. Working on the form today.
How do you set up your schedule to conference on all clients?
At SOC, any time of need, recert, prior to d/c? My nurses carry caseloads of 20 and up...I can't figure out how to get these notes in every 14 days..on all clients?
- 0Aug 19, '03 by hoolahanWe had a "box conference" on all our cases q 2 weeks. Sat w super and rev'd all cases in our caseload (or tickler cards in our box.) I have never seen a supervisor document a case conference yet in my former agency. I am not sure how/if they do it at my current agency.
I didn't realize this was a JACHO requirement. What are they looking for? Evidence that the case was discussed w a supervisor?
Karen, your form looks more like a guide for a case manager to document ID communication. Are your supervisors following behind the case managers with all the disciplines as well?? I was always sure to document my own IDC, I just thought that was what CM's are supposed to do?? I didn't realize I needed to document IDC w super as well, but if I discussed a case w a sup, I did document it.
- 0Aug 19, '03 by NRSKarenRN AdminI always case conferenced with nurses + PT on my team every two weeks. Each staff assigned different day--none on Mondays.
One week was just done via phonecall/voice mail other was done live monthly.
I managed 200+ office of aging long term clients + 25-30 insurance cases --- used an excell spreadsheet to keep track of patients and RN case managers. Every 3 months would check charts in file room to make sure nobody missed.
Every time I received report from therapies/RNs for visit auths, I filed out form. Made joint visit's on long term wound pts and any "problem clients" Instead of jotting those notes down in a notebook, I used the form., signed off and slipped into chart. Became second nature to me after 3 months.