Multiple Charts?

Specialties Home Health

Published

Specializes in OB,HH.

Our HH agency uses 3 charts for each pt and I am wondering if there is a way to streamline this crazy set-up? There is a "hard chart" that stays in the office and holds paper copies of orders, H&P, HHA notes/care plans etc. Then there is a "travel chart" a manilla folder with copies of (hopefully) up-to-date orders,med list, a zillion teaching flow sheets and a calendar- this one goes with you on a home visit. Then there is the "computer" chart where you must enter all the oasis and 485 junk on a 40 something page data entry for an admit or recert and do daily nurses notes.

Just to set up all this stuff and actually go see the pt, it takes (me) at least 4 hours for an easy admit. When I have an admit I am handed a printed out 3 page thing called "demos" that have name, address, primary dx and maybe a med list- I have to gather up and put together all the various charts and go do the admit assessment. We have laptops but not enough for everyone so usually end up doing data entry in the office or at home. Recerts are a nightmare of updating all those zillion flowsheets, changing the dates and updating (1 at a time) every goal in the plan of care and a new oasis data entry with no way to see most prior entries. Im frustrated with this system but dont know anything else to compare to- does this sound crazy or frightengly familiar??

As far as I know all the agencies I ever worked for only maintained two charts: the big one in the office, and the field chart kept in the home. An individual nurse would get a copy of the 485 and current medsheet prior to going out to a new case, if they asked for it. No computer charting yet, so any computer generated stuff limited to that done in the office. Don't know what to tell you about this. I guess all that trouble you go through updating on recerts must be a pain. I would think that new entries should automatically go into each file that requires the info. Something for the programmers to take care of. Glad I don't work with computer charting.:banghead:

Specializes in Home Health.

My goodness, the point of software charting is to make your life easier with less redundancy. What system do you use? A good system will allow you chart once and never have to reenter demographics, meds etc. Your system must also be a nightmare for QA and compliancy issues. EM me and I can talk to you more about our system.

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