Help!! How to document clinical info narrative - page 3
I'm an experienced RN but new to home health nursing; especially skilled nursing documentation requirement, OASIS, 60 day summary. I was hoping those of you with experience could be of assistance to me. I work for a new, small... Read More
- 0Nov 25, '12 by KountryPrincessEveryon at our agency charts narrative differently. Most nurses use Word templates, especially for revisits. We are required to use templates to document wounds and ostomies. Remember that your OASIS and other flow charting contains a lot of assessment info, so what I try to focus on in a narrative are my patient's specific issues that exist and exactly what teaching or actions I am doing to rectify the situation. I do a lot of Start of Care visits, and I was trying to use templates for various issues, but it is not working the greatest due to the wide variation in pt situations. What I have done now is handwrite a teaching guide for all different dx and what I want to make sure I cover with each of those dx. When I am looking over a SOC packet at my pts hx, I then start listing on a post it the dx for that particular pt that I want to address. During my visit, I go down my list and may flip back to my teaching guide to make sure I am covering everything. I make pertinant notes on the post it regarding that pt, specific issues etc. that I may address or need to fu on. Then when I sit down to write my narrative I just run down that post it, include the pts particular issues and what I did about them, reaction to teaching, and what we need to fu on at the next visit. Basically I use the post it as my brain trigger to get all pertinant info into the narrative. I have been doing home care for 10 years and our teaching and disease mgmt protocols are getting more and more detailed. I was finding I would spend ages with a pt, doing tons of discussion and teaching and then forget something silly like asking them if they had their flu shot. Grrr. so far this is working well, we shall see.