Computer use in Home Health

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    How many of you document using computers/laptops/handhelds? Do you like it?

    We are still on paper. The company seems to add another document monthly. Making me nuts! When I retire, I will ban ink pens from my home!
  2. 9 Comments so far...

  3. 0
    I've used both. Depends on the program, sometimes paper is actually faster. The best thing with the computer systems (most of them anyway) is that they prompt you so that you don't turn in incomplete work.
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    I've used both also and paper was faster for me. However, once I know the program really well I can document fairly quickly on it, but sometimes not in the home, because my patients don't like to stay on point. I ask about pain, they answer then start in on how cute their 10 grand kids are, etc, etc. But when on paper I was able to jot things down and get it organized in the home easier, then on computer.
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    I have a laptop that I do everything on. As this was my first nursing job I do not have the ability to compare paper charting to computer charting, but I do know I can type a heck of a lot faster than I can write.
  6. 0
    A colleague does intermittent visits for a second employer and uses a handheld. I have observed her doing charting and it is not a very fast process. She told me that it still takes her almost as much time as paper charting and when there are technical problems she is stuck and can't do her job at all. I prefer paper charting. There is little room for possible tampering, since handwriting can be identified. I was once asked about this in a job interview and the panel nodded in agreement when I told them my opinions.
  7. 0
    With our computer system we MUST leave our charts unsigned for the clinical managers to make changes. They are suppose to notify us of the changes in case we disagree, then we can lock the SOC, D/C, Recert. I personally think this is ridiculous, since they weren't the ones who saw the patient.
  8. 0
    Quote from RN1263
    With our computer system we MUST leave our charts unsigned for the clinical managers to make changes. They are suppose to notify us of the changes in case we disagree, then we can lock the SOC, D/C, Recert. I personally think this is ridiculous, since they weren't the ones who saw the patient.
    Talk about micromanagement. I can see more of a reason to do this with SOC, DC, and Recerts though. I can't see it for day to day shift or visit charting.
  9. 0
    Quote from caliotter3
    Talk about micromanagement. I can see more of a reason to do this with SOC, DC, and Recerts though. I can't see it for day to day shift or visit charting.
    I am referring to SOC, D/C, ROC and recerts, not day to day visit charting. Management has the ability to unlock my SOC, Recert, whatever and make changes, but I was told this would leave a paper trail and raise red flags. Is this typical practice? We were allowed to sign before, but not now with McKesson until review is done.
  10. 0
    Quote from RN1263
    With our computer system we MUST leave our charts unsigned for the clinical managers to make changes. They are suppose to notify us of the changes in case we disagree, then we can lock the SOC, D/C, Recert. I personally think this is ridiculous, since they weren't the ones who saw the patient.
    Here is one better than that. We are on paper, case managers make changes to assessment questions, then fill out a form showing the changes and noting that they have spoken to the assesssing clinician. The clinician is to then change the answers on the paper oasis. Problem is, they do not speak to the assessing clinician, the changes are already made and oasis submitted, before the clinician gets the form. I have on occasion, noted on the form that I disagree and signed same and placed in filing without changing Oasis answers. I know that they do not have the right to change assessment answers at any time, for any reason.
  11. 0
    Quote from RN1263
    I am referring to SOC, D/C, ROC and recerts, not day to day visit charting. Management has the ability to unlock my SOC, Recert, whatever and make changes, but I was told this would leave a paper trail and raise red flags. Is this typical practice? We were allowed to sign before, but not now with McKesson until review is done.
    Yes, this will leave a 'computer trail', unless the systems were destroyed, and I guarantee you they won't, since everything is backed up approx every 15 - 30 seconds. If they are making changes, they need to speak to you and get your agreement and then they need to make a notation in the notes section of what was changed, why and that you agreed. Home Health is so big, problem is, they know Medicare will never be able to keep up with all of this fraud.


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