Here is an example of a clincal finding narrative for SOC

[paradiseboundRN]

I read a lot of posts asking for help with a narrative so here is an example for a SOC

PATIENT IS 78 Y/O FEMALE POST HOSPITALIZATION FOR EXAC OF COPD. INDEPENDENT PRIOR TO HOSPITAL PMH: COPD, CAD, HTN, ANEMIA, NIDDM. CURRENTLY, A&OX3, VITALS WNL. USES 2L/NC OXYGEN CONTINUOUSLY. DYSPNEA WITH MINIMAL EXERTION. LUNGS SOUNDS DIMINISHED BILAT. NEW NEBULIZER AND RX FOR ALBUTEROL. ADMITS TO STRESS BLADDER INCONTINENCE. POSITIVE BS X4. SHE HAS A 0.5 X 0.5 X 0.2 CM WOUND (SKIN TEAR) ON HER RIGHT ANTERIOR FOREARM. POSSIBLE TAPE BURN. WOUND BED IS BRIGHT PINK WITH NO DRAINAGE. BANDAID APPLIED. FBS 110 TODAY AND COMPLIANT WITH GLUCOMETER AND 1800 ADA DIET .EDEMA: 2+ PEDAL BILATERAL, LEFT INSTEP 28CM, RIGHT INSTEP 26CM. RATES PAIN 2/10 IN BACK DUE TO ARTHRITIS. UNSTEADY GAIT, USES WALKER. INDEPENDENT WITH ADL'S EXCEPT BATHING. LIVES WITH BROTHER WHO IS MAIN CAREGIVER. PLAN TO TEACH COPD DISEASE PROCESS AND MANAGEMENT; TEACH MEDICATIONS, SAFETY, NEBULIZER, HOW TO DECREASE EDEMA. MONITOR WOUND.

Basically you need to write the story. What were they in the hospital for? Medical HX? and then go through this list. I usually chart by exception, meaning that if I didn't mention it, it does not pertain or is normal. I added normals to this example so you could see how its done. All of this assessment data is in the OASIS anyway but most agencies want you to write a narrative. I might have missed something but this is the basics. Hope it helps.

orientation

vitals

lungs

oxygen

exertion level

bladder/bowel

wounds

pain

edema

FBS if diabetic

diet

ambulation

assistive devices

ADLS

support system/CG

new meds (coumadin, insulin)

new DME or equipment

[BedsideNurse]

Computerized charting was supposed to free up nursing to spend more time at bedside, but as usual we have been and continue to allow our practice to be totally sabotaged. Nurses are either running around like chickens with their heads cut off, or glued to the computer. This is the new normal. I've had older patients patients notice and comment on the change they've seen in nursing. :/

A friend of mine is an RT that does home care, vent set ups, assessments, follow up and CPAP's, makes more than me an hour and has almost no paperwork. She says her paperwork is inconsequential to her day/ like super quick in a couple minutes per patient, not even an issue. So respiratory therapy in the home has figured out how not to strangle the therapists, but nursing can't?

(Sigh...)

[Libby1987]

Delete

[TristleRN]

I agree; I have worked home care and really enjoyed the job... love seeing this side of the hospital... however, the documenting is ridiculous. I tend to write very long narratives that give a detailed story... in addition the time it takes to do OASIS and all the other stuff that are required to be done on SOC. I was told by higher ups that I documented "too much." In frustration, I shrug my shoulders. The physical therapists make a lot more money than I do despite my almost 30 years' experience and their charting is so much better.... minimalistic compared to ours.

[jlourd22]

Homecare can at times be the worst thing. Some of these agencies are really taking advantage of Medicare and the poor nurses who have mountains of papers to do FOR FREE while these companies keep getting richer and richer. The worst part is if you get stuck you can't do anything else since you use 0 skills. I blame the nurses who let them take advantage of them.

[ajqueenie, BSN]

Its not agencies that want the narrative, its CMS. Additionally one needs to document to homebound status with supportive and qualitative statements. One should hold off on noting any independence in the narrative unless follow up with deficits. Document to OASIS M and GG items for tasks completed safely. If parient is performing a task, are they doing it safely. Be sure and get the team members assessment info and their input if other disciplines are involved. I would caution stating “ Patient is independent for all ADL’s except for bathing”.

Would be good to get refresher in OASIS Esp in current OASIS D. The narratives need to paint the picture of why HH / why now. It is even more imperative as the new PDGM rolls out in 2020.

RN, BSN, QA

[ajqueenie, BSN]

On 12/12/2018 at 9:42 AM, jlourd22 said:

Homecare can at times be the worst thing. Some of these agencies are really taking advantage of Medicare and the poor nurses who have mountains of papers to do FOR FREE while these companies keep getting richer and richer. The worst part is if you get stuck you can't do anything else since you use 0 skills. I blame the nurses who let them take advantage of them.

You don’t use any skills in Home Health? Patients on HH require skilled care - if they don’t, they should not be receiving services. Its Medicare that requires all the documentation - not the agency that's calling the shots.