To be perfectly honest, if the pt is known to me, and I know they know the s/s hi lo bs, then no, I would not check that off. Why? B/c it has to be addressed in the discharge as a met goal, and in notes, etc... To much triple documentation.
I am not sure what you are talking about with that question for homebound status, and you saying for the "Other" section? Where there is a fill-in-the blank?
If so, you can add a spot for related to
[ ] Other _______________ related to _______________
Frankly related to should be addressed in the care plan or in their notes. One I like to use is "Post-Op weakness" or "Post-Op mobility limitations."
I have written decreased endurance, but I didn't clarify it, b/c usually when I use that, I have already checked off dyspnea w min exertion in the resp questions, so I would hope it doesn't need further clarification and repitition than that.
I don't like the term generalized weakness either, that is too vague. It should have a disqualifier or simply not be used.
Unsteady gait, I have no pronlem with that, it should be supported in the prior neuor or M/S questions, and the ADL questions, what more clarification does that need? Isn't that one of the actual options to check? If CMS/HCFA doesn't have a problem with it, I wouldn't worry about it.
Now back to the DM question, to clarify, I re-read your ? and do see the issue, makes it look like the DM issue was not adressed. When I have a known DM, who maybe is not known to me, but has been DM for a long time, then yes I do at least go over the s/s to be sure they can verbalize what the s/s are, and appropriate emergency measures to take. What I document is "Client independent w DM management." But in my narrative, I would elaborate that they were able to verbalize s/s hi/lo BS and appropriate actions for same.
If the nurses have "always done it this way," you can expect a lot of grumbling. Put out a memo, or do an inservice so they know what you expect. Nothing is worse than being called back by QA to be criticised, even if it is constructive. Address it to everyone if they all do it that way, It will waste less of your time too. Or put out a note they need to sign and return to you, so THEN if it keeps happening, you can say they have been instructed not to do that.
Some people really are just not good at documenting. I'll tell you, if you remember how much paperwork you did in the field, it is enough to make you just want to walk away when those little things are noted. I am not implying it is petty, we know it is important for reimbursement, just have to pick and choose your battles carefully. Have you ever been questioned, or had this documentation called into question by a surveyor? If not, it may not be worth your energy to tyr to change people. Why not ask someone from Jacho or CHAP or whoever you use?