Help!! How to document clinical info narrative

  1. 0
    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 agency that is getting ready for its first initial state survey. The agency is owned by an RN but her home health experience is limited; therefore my orientation was somewhat challenging. But she is a good friend and I'm trying to help her out.

    I've done extensive research on OASIS, read the user manual on CMS website, view an online course but I'm still confused about some parts of it. I'm having problems with the part where you have to write a narrative as I don't know what to write.

    For example:
    (1) Endocrine/hematology Disease Management Problems(explain)- what do I write
    (2)Pain
    How does the pain interfere/impact their functional/activity level(explain) what do I write
    (3)Cardiopulmonary Disease Management Problems(explain)- what do I write
    (4) Fall risk assessment
    The patient is a high risk for fall but then the question ask: plan/comment
    Do I document fall risk interventions or what do i write?

    (5) Living arrangement/supportive assistance
    If a patient lives alone, but has a paid caregiver who assists with household chores. Does that counts as a primary caregiver?
    (6) what has to be included in a 60day summary of care? A sample would be greatly appreciated.
    (7) Skilled nursing note- I was told it has to justify why home care is being provided and speak to the plan of care and contain certain phrases or words. If someone has a sample they want to share.
    (8) Those of you that have been through the survey process, what should we expect?

    Any assistance is greatly appreciated
    Thanks,
    Last edit by NRSKarenRN on Sep 9, '12
  2. 23 Comments so far...

  3. 1
    Your manager should have some good examples ready of what they are expecting you to write. Put this in a Word document that you can copy and paste into charts, then tailor to your specific needs.
    Not_A_Hat_Person likes this.
  4. 0
    Write to me off forum at KateRN1 at hotmail dot com and I will help you as much as I am able.
  5. 0
    KateRN1
    I tried emailing you at the email address provided but email was undeliverable.
  6. 0
    Try again. That's my email address. Plenty of others have used it without difficulty.
  7. 0
    KateRN1,
    Got the documents
    Thank you so much
  8. 0
    Hello Katern1 I'm also new to home health care and having difficulty finding verbiage to the same questions. Do u still have a copy of the Word doc? If so please forward to paulaopoku@cox.net I would greatly appreciate any help you can offer.
  9. 0
    Please also email it to me amanorr@msn.com thanks!
  10. 0
    Starting my first home health care job tomorrow! Any chance I could get on that bandwagon, KateRN1? I would love a copy of that document too. Thanks soooo much. I'm at mar.mt@comcast.net

    Marie
  11. 0
    Hi KateRN1. Would you mind sending me a copy of that document as well? Our summaries are so lengthy and we really want to revise our form. Thanks so much!


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