Help!! How to document clinical info narrative

[RNBSN95]

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,

[KateRN1]

I think I managed to get it sent out to everyone who requested. It's hit and miss how often I make it to AN due to work schedule, kids, and general mood, so feel free to email me with questions. Email address is posted earlier in the thread.

[nursebabyjan]

Kate could you send me a copy of the forms too? Thanks! Send to [email protected]

[gayarn]

Kate,please send me a copy of the forms. Thank you! [email protected]

[paradiseboundRN]

This book will help although it hasn't been updated to OASIS C yet.

[h=1]Handbook of Home Health Standards & Documentation Guidelines for Reimbursement[/h]

T. M. Marrelli

[/url] 0 Reviews

Mosby, May 22, 2001 - 680 pages

A standard reference in the home health market, HANDBOOK OF HOME HEALTH STANDARDS & DOCUMENTATION: GUIDELINES FOR REIMBURSEMENT includes everything the home care nurse needs to effectively document care based on accepted professional standards. For each of the more than 60 clinical problems included, this handbook offers detailed standards and documentation guidelines including ICD-9-CM diagnostic codes, service skills, factors justifying homebound status, outcomes and goals, discharge plans, and specific tips for reimbursement.

[nurseklg]

Actually the OASIS C is in the book. Its out now! I just ordered mine from Barnes and Noble!

[ez2000]

hi kate, i hope you don't mind me ask/ng the same thing. can you share it to me as well? my email is at [email protected]. thanks a lot in advance! i owe you one.

[MsDorsey]

Hi Kate! I sent you a email. Hope you don't mind sharing with me as well. [email protected] Thanks for being such a GREAT resource to the nurses here!!

[NRSKarenRN, BSN, RN]

Admin Alert:

Posting email address in threads allows spam bots to get hold of your account since allnurses is heavily indexed. Please use our Private Message system for requests.

I've used Marrelli's Handbook of Home Health Standards & Documentation Guidelines for Reimbursement book since first edition published in late 80's. Newest 5th edition is also available on Kindle.

[Coastieskid]

Sep 19 by Coastieskid

Hi Kate! Hope you don't mind sharing with me as well. [email protected] Thank you in advance for helping out new healthcare nurses.

[annbabol]

Hi KateRN1 would you mind sending me a sample of narrative nursing note for home health care. Thank you so much.

[KountryPrincess]

Everyon 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.

[Cyoung07]

Hello can i get the word doc as well..i am new to HH...also does anyone have a copy of SOC packet that they can email me..I am trying to get myself familiarize before i go out..

[email protected]