CHARTING AND DOCUMENTATION help!
- 0May 17, '11 by MsRN247Hi. I have been a HH nurse for almost 1 year, but I feel the need to improve my documenting skills. IF there are nurses out there who would be able to give me guidelines, on regualar SN notes.. I think i got OASIS down lol. Any help appreciated! thank you in advance!
- 21,906 Visits
- 3May 27, '11 by HmarieDRemember that every single clinical note must stand alone, in other words you should be painting a very complete clinical picture every time you document. Your documentation of tasks such as wound care must echo your plan of care, and should be in excruciating detail (cleanse w/___, apply___, cover w/___, secure w/___, aseptic technique). Remember to document any and all care coordination (communication with any member of the health care team including caregivers, DME providers, physicians, clinical supervisors, etc etc). Always address progress (or lack of progress) toward goals as they are stated on the plan of care. Always make sure you are demonstrating homebound status if applicable, and skilled need and medical necessity. Indicate why the pt continues to require HH services.
These are just some of the areas I do not see done well when I audit a record.
- 2May 28, '11 by HealthyNurseI often find that home health nurses forget to document a complete head to toe assessment with every visit. It doesn't matter if you've seen the patient 10x or 200x before- you still need to document the entire physical assessment. Also, if your patient has a urinary catheter or PICC line- you need to document the appropriate assessment of those items as well (18 fr cath, 10ml balloon; double lumen PICC in right upper extremity, etc.).
It is very important that you document your patient teaching appropriately as well. Indicate who you taught (pt or caregiver- and who the caregiver is) and the details of what you taught. If you use a standardized teaching tool and a copy is available in the chart or at the office for reference, it makes it easier to document because you can state "Instructed pt on signs and symptoms of hypoglycemia via Prichard Hull teaching tool". However, if you don't have a standardized teaching tool, you should indicate what it is exactly that you taught on (i.e. "Instructed pt on signs and symptoms of hypoglycemia, including hunger, dizziness, shakiness, sweating, anxiety, and weakness."). You should also indicate the patient/caregiver's response to your teaching. If the patient demonstrates or verbalizes complete understanding, you could choose to reinforce the teaching during your next visit or test the patient on their knowledge, but you shouldn't keep documenting that you are teaching on the same thing. If the patient already has the knowledge, it does not support a need for continued skilled care.
- 0Jun 11, '11 by alneil77Hi everyone , I am also a brand new nurse and I just started doing home health and I'm having a hard time on charting and documenting i graduated a while back but I just recently passed my boards and hospital job is a little tough right now to get in so I kinda landed in home health care . I even have to volunter to shadow one of the nurses for a few times but she didn't really explained how to do it. Now I have all these 3 cases I opened last week and still not able to complete my notes. Cn anybody please help me.!! Can u guys send me some examples of of comprehensive assessment and some follow up visit notes... I would really appreciate it.
- 14Mar 24, '13 by paradiseboundRNThis is an example of a clinical summary for a SOC. Sorry about the caps but I copied from a real assessment and our system forces us to use caps.
PATIENT IS 78 Y/O FEMALE POST HOSPITALIZATION FOR EXAC OF COPD. INDEPENDENT PRIOR TO HOSPITAL PMH: COPD, CAD, HTN, ANEMIA, NIDDM. CURRENTLY, A&OX3, VITALS WNL. USES 2L/NC OXYGEN CONTINUOUSLY. DYSPNEA WITH MINIMAL EXERTION. LUNGS SOUNDS DIMINISHED BILAT. NEW NEBULIZER AND RX FOR ALBUTEROL. ADMITS TO STRESS BLADDER INCONTINENCE. POSITIVE BS X4. SHE HAS A 0.5 X 0.5 X 0.2 CM WOUND (SKIN TEAR) ON HER RIGHT ANTERIOR FOREARM. POSSIBLE TAPE BURN. WOUND BED IS BRIGHT PINK WITH NO DRAINAGE. BANDAID APPLIED. FBS 110 TODAY AND COMPLIANT WITH GLUCOMETER AND 1800 ADA DIET .EDEMA: 2+ PEDAL BILATERAL, LEFT INSTEP 28CM, RIGHT INSTEP 26CM. RATES PAIN 2/10 IN BACK DUE TO ARTHRITIS. UNSTEADY GAIT, USES WALKER. INDEPENDENT WITH ADL'S EXCEPT BATHING. LIVES WITH BROTHER WHO IS MAIN CAREGIVER. PLAN TO TEACH COPD DISEASE PROCESS AND MANAGEMENT; TEACH MEDICATIONS, SAFETY, NEBULIZER, HOW TO DECREASE EDEMA. MONITOR WOUND.
Basically you need to write the story. What were they in the hospital for? Medical HX? and then go through this list. I usually chart by exception, meaning that if I didn't mention it, it does not pertain or is normal. I added normals to this example so you could see how its done. All of this assessment data is in the OASIS anyway but most agencies want you to write a narrative. I might have missed something but this is the basics. Hope it helps.
FBS if diabetic
new meds (coumadin, insulin)
new DME or equipment