I am working on a staff inservice for general home health documentation. I have a lot of tips from websites regarding defensive documentation, words to avoid ("stable", "encouraged") etc, but I was hoping that some of you old home health vets could give me some good tips to pass along, like your personal pet peeves (for example, "teach & instruct" - umm, could you pick just one please?).
Thanks for your help.
Aug 14, '09
This one is so simple, but so many nurses I've worked with haven't quite got it: document according to the 485 for things like goals, interventions, what is needed/being taught, etc.
Aug 14, '09
Very basic. Address the care plan in your charting. See it all the time. Ordered interventions are not charted as being completed, so one believes that they were not completed. Like Kate said, this is seen often. I don't want my boss criticizing me for not doing what is on the care plan, especially if it is just because I didn't chart it. Another item, although not directly part of charting: We were told that we are not to scribble or write stuff all over the home chart copy of the 485. I would think that this one would also be common sense, but there is always someone who does it. And another one: Many nurses can't be bothered with any other paperwork than what will get them paid. They don't do necessary Supplemental/Telephone Physician's Order forms to cover changes between 485 updates. It takes what, all of ten or fifteen minutes at the most to write the form up, then you put the hard copy in the mail to the office? That is part of documentation also. But it seems many think that it is someone else's responsibility to do these, never their responsibility. Well, there are other examples, most of them are all the usual it seems.
Aug 17, '09
Thanks. I see all of those things as well, hence the need for inservicing. We cover this stuff in orientation but usually your head is spinning at the end of all that, it just doesn't seem to sink in. Some of my older nurses are the worst offenders, old habits die hard.
Still open for suggestions, venting is also good
Aug 17, '09
I always write Assess/Instruct in s/s of CV/CP documentation for intervention. Then you are defining what you do always assess and always instruct. You can and should go into specific interventions, but this sets the tone for what is to follow. I, too think Teach and Instruct is the same! More hints to come your way
this wkend. Need toget some sleep right now, it's a luxury for me these days. Way too many issues at my agency. Hint--If you take care of your nurses, they'll take care of the patients. If a company burns them out, then, they'll be looking for a new position, already have 2 offers, NOW, I know what to ask the interviewer, I learned the hard way!!
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