Exactly how specific ?

  1. Home health managers have been telling nurses that they have to be specific in their teaching .....specific to the point of ridiculousness

    example: teaching a patient on the side effects of Norvasc:

    "Instructed pt on side effects of med norvasc: headache, dizziness, drowsiness, flushing, tired feeling......patient is able to recall headache and flushing"

    Is this really how it needs to be documented? and does medicare expect other areas of nursing to do the same thing? such as on busy med surg units?

    dont even get me started on how they want us to document wound care......every little step and every item used has to be documented.
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    About LaRN

    Joined: Dec '02; Posts: 278; Likes: 351


  3. by   paradiseboundRN
    I'm not sure about how the hospital nurses chart. I haven't worked in the hospital for 11 years. But you are right about home care. That is the expectation. This is where computers come in handy. I would type these type of things once and cut and past them into the documents as needed. It saved me so much time.
  4. by   salvadordolly
    HHA's are getting increasing ADR's/denial of payments because charting is vague. We had one denied for "provided instruction in pressure relief techniques". they wanted to know specifically what was taught, some are asking us to document what teaching methods were used as well. I feel your pain, they're getting so picky!
  5. by   LaRN
    cut and paste it is then !!

    picky is an understatement.....but there is no real clear expectation of what it takes to satisfy medicare....bc never know who will being doing the judging........there are the ZPICS, RACS, MACS, And any other hurdles they may come up with.

    its ridiculous that on patients who have a lot going on such as picc lines, drains, dressing changes, new meds, home health aide services, just one 45 minute visit can result in over another half hour of documentation. and god forbid the nurse forgot to document that they allowed the alcohol to dry before applying the tegaderm !