Homebound Reasons

hoolahan, ASN, RN · Oct 24, 2002

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

eg

[ ] 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?

KP RN · Oct 24, 2002

I agree with Hoolahan, Cardio. Our agency doesn't require us to double or triple document the facts. Generalized weakness, decreased endurance, unsteady gait has been sufficient. As far as the diabetes teaching goes, the nursing assessment (whether incorporated in with the oasis or separate) should have included type of DM, type of glucometer, how frequent FBS done, who does the checking, and whether further teaching is needed.

It's tough out there in the field. Maybe your nurses are unsure of what you are specifically asking for.

When I started with my most recent (ahem!) home care agency, I spent several hours in the office reviewing charts from senior nurses. It gave me great specific ideas on how to improve my documentation.

Maybe you could do an inservice at one of your staff meetings and make copies of really well written documents and notes which would include all the necessary lingo and catch phrases??

renerian, BSN, RN · Oct 24, 2002

I have learned one thing about home health and OASIS. There is more than one way to skin a cat. Different agencies do things very differently. If you are thinking about changing how they document you need to go in armed with publications like Direction, Home Health Line or JCAHO pubs. I say this because in the ever evolving interpretation of OASIS and state regs, JCAHO regs you need to have with you a current evaluation of exactly what those bodies veiw as legitimate. Does that make sense? I have done alot of research into how people document and if you go in like gangbusters without these interpretations for very respected publications you will have a whole bunch or irritated nurses......I don't mean to sound bad or hurt your feelings it is just so important to get your ducks in a row. Find out who the office person that is a nurse that they identify with and present the information in question to him or her first to gain an edge, someone to concur with you. Does that make sense? Does this help you any???

renerian

CardioTrans, BSN, RN · Oct 25, 2002

Thanks for the replies....... I talked with the clinical supervisor about this yesterday....... she has been trying to get some of the nurses to be more detailed with homebound reasons and with their documentation in general for months, alas to no avail. Her words were "they dig their heels in". Some of the things I have asked them to do were brought up in a staff meeting and handouts were given from various references. They dont "case manage" here and different nurses see the patients..... so there is no one nurse for certain patients. Thats why the clinical superv has been after them for details so the nurse that goes behind them can look at their notes and see exactly what has been taught and etc. The last 2 staff meetings she has brought up that she wants them to start their notes with "SN visit for......" but no one has seen that yet. One day and one battle at a time I guess. Again thanks for the replies.

hoolahan, ASN, RN · Oct 25, 2002

Wow!! No wonder this is such a big issue w no case managers.

One thing we were required to do is be sure to document homebound status at least once a month. But, if no one case manager, every nurse seems to think another nurse will do it. Grrr!!! Just like wound measurements and daily wounds. I was per diem, and it used to peeve me off that the case manager would never do VS, or wound measurements, would dump that onto weekend nurses, ie me! I am so anal, of course I would do it, but as the CM who is in contact w the wound care center during M-F biz hrs, you would think she would be interested! NOT!!

So, if it was that difficult w CM's I can only imagine how hard it is w.o them.

In that respect, I have an idea for you. New nurses notes!! You need a check off format, designed to capture the info you want.

One of the agency's I worked for did this, had a spot for homebound status, and a spot for managed care

Visit ___ of ___ auth'd through __/__/__

How on earth do you capture interdisciplinary communication w/o a case manager??

You could put that on the form too

Disciplines ongoing PT OT ST MSW

Interdisciplinary communication made after this visit?____________________________________________________________________________________________________________________________________________________________

(circle which disciplines, and have them write just a simple "VM to PT John B re progress to date?")

Then a wound care section w circle the answer options.

It turned into a two page format for every daily note.

One other ?, is the sup reviewing notes before they get filed?? I mean really reading them? B/c, if our notes were not complete, they got handed back. That was something that always frustrated the living hell out of me, so I tried very hard to be comprehensive and get it right the first time.

All I can say is be gentle. I have witnessed several meltdowns over paperwork being handed back for improvements. It wasn't pretty!

CardioTrans, BSN, RN · Oct 25, 2002

OK... get this....... the regular visit notes are "circle the appropriate" kinda thing. At the end of the day, they check off the visits with the LPN that works in the office. The LPN in the office does everything that a case manager would. She communicates with the other disciplines involved, she does the transfer to inpt facility oasis, she calls orders to the docs, or faxes them, she faxes all the labs, and gets the new orders for labs, she marks the visits off the calendar, and even helps make out the schedules for the next day, etc......

The clinical supv reads over the basics of the adm OASIS, makes sure the diagnoses are in the order they should be in....... then sends it to the clerical person for her to key everything in....... then it comes to yours truly to QA and finalize the 485. I am the one who gets to hand them back (keep in mind that I have already been told that I will not be "liked") lol

I know things cant be changed overnight or with the blink of an eye, but alot of things I am finding ie the teaching or at least asking on admission about the diabetes is knowledge that the nurses should already have, no one should have to remind or ask them if it was done. I hope that didnt sound cruel or hateful, thats not my intention at all........ I guess I have been doing home health for so long that I am just "set in my ways" lol

hoolahan, ASN, RN · Oct 25, 2002

PM me your work fax, and I will fax you the notes we used. You may find them really helpful anyway. But probably not til Monday, have to study for CCM exam on Saturday!

Sounds like you guys have some process issues, but what agency doesn't???

Do your nurses have to participate in QA? We would have to take a chart a month and do a QA. You could do a staff meeting with a bunch of old charts, and give them the QA forms, have them QA each other's charts, but start by doing one together, have them count the # of visits made, see if it complies w orders, etc...

Have they ever seen the form of what you are expecting to find when you do QA? I know I learned the most by being involved.

newLPN04 · Aug 21, 2008

We have one RN who always puts: Poor mobility with functional limitations. Taxing effort on pt to leave home.