Need Charting Help

  1. I ran across this discussion board "by accident" when I was looking for information on home health nursing. I am currently working as a home health nurse.
    What I am looking for is charting information on nurses notes on a visit. What do you say? How do you say it? What do you include? How do you do all this in a way that is acceptable to Medicare?
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  2. 11 Comments

  3. by   renerian
    Most companies have checklist charting for the body systems which helps and you only need to write in the narrative section the abnormal things, education, their knowledge retention and such. Wounds alot of time fit in there as it tends to be lengthy and cannot fit in a box. Dr. or phone calls, hha education or proceedures, blood draws where/tolerated.

    What does your nurses note consist of?

    renerian
  4. by   Turtle62
    Hi Nurse Candy. It sounds as though home health may be new to you. Home Health documentation is a little different than documentation in other settings. While you still must include your patient's assessment, any procedures that you perform, your instructions to the patient, and their responses to all the above, you also have to remember how to document for reimbursement. If you are new to homecare, it is a lot like learning a new language. My best advice is to review your notes with the performance improvement guru in your agency, she/he will know what wording to use to make your notes the best they can be. If your agency does not have one person assigned to performance improvement check with your immediate supervisor and ask for a mentor until you feel comfortable. Good luck-Turtle62
  5. by   sb22
    I agree-have someone review your notes-as nurses we tend to do the care but not take credit, with someone else looking at your note they can offer suggestions.
    Just remember that in home health you are assessing the patient for the whole time since they were seen last by someone in your discipline. (If SN sees the patient once a week, you have to assess for the past week, etc.) Also, you must make each note make a complete picture of the patient with every visit, so there will be repitition from note to note. A note must be a ble to "stand alone". If an auditor only pulled one note from the chart, they must be able to tell all about that patients condition based on your one note.
    Hopefully your agency has a check list for the head to toe assessment and you can just chart on the things that are not "normal".
  6. by   Traveler
    We now have a 2 sided checklist for all body systems, have spaces for IV's, injections, vp's, etc., space for homebound status summary and a little space for extra stuff. We used to write a note and we were supposed to cover all. The others were right, you need to paint a picture of the patient and what they are able to do. When I was orienting to home care, I was told by a nurse that in a way you have to focus on the "bad" because you have to show why we need to be in there. I personally preferred the notes over the checklist and a typical note would go something like this: Pt. alert and oriented to person, place and partially to time. Periods of confusion noted. Skin warm, dry and pale. PPP with 1 plus pitting edema BLE. Food and fluid intake good per pt report. BS present without constipation. Voiding without difficulty with occ. urinary incont. reported. Lungs CTA without cough. Resp. even and unlabored. SOB on min. exertion. Ambulates slowly with difficulty. Holds to walls/furniture. Uses walker PRN. Requires assist with bathing and cannot leave home ind. B12 inj. 1000mcg/1cc IM L deltoid. No adverse reaction after 20 minutes. Pt inst. on med change (Lasix 20mg to 40 mg) at last MD appt. 082003. Inst. purpose of med is to decrease fluid. S/e incl. N&V, electrolye imbalance, increased urination. Inst to take pref. in the am and to increase K intake including bananas. In't. to report s/e to md or hh and to report increased edema in ankles and any prod. cough. Pt denies all s/e other than increased urination.
    I may have missed something but that's how we used to do it and that's how I prefer it. The checklist takes less time but it's kind of sterile. Guess I'm old fashioned!

    Ann
  7. by   hoolahan
    This book is great too....

    T. M. Marelli's ---The Handbook of Home Health Standards and Documentation Guidelines for Reimbursement, "The Little Red Book" (Mosby)
  8. by   wcnurse
    look at the 485, then under your skilled nurse note, you address everything thats listed. for example...
    O/A all body systems. vss. wound care per order, no s/s of infection at wound site. meds checked and appropriate for compliance. No s/s increase or decrease glycemia. Pt. voices pain level at a 2 on 1-10 scale.
  9. by   tburrell
    Hi. It really does my heart good to see a new home health nurse who is willing to go to some length to find out how to do something; in this case documentation. I am the Director of Clinical Services for a home health agency. Documentation is one of the most important things you will do.

    I always tell my new nurses (those new to home care) that this is the most autonomous you will ever be. You must enter the patient's home and immediately assess the entire environment, family dynamics, potential for abuse, exploitation, etc., the patient's financial situation and if you need to call in a MSW contract. Then you get down to documentation. The old saying applies even more in home care "If it is not documented, it was not done". You need to document what you taught the patient/caregiver, their understanding of the instruction, your plans for further instructions, any abnormal findings upon your assessment, as well as documenting the normal findings such as Lungs clear to Ascultation. As the other nurses have pointed out, hopefully, you have a check off visit note which guides you through the head to toe assessment. Remember, you must assess the whole patient each time you make a visit. That means an assessment for the Cardiopulmonary, respiratory, integumentary, GI, GU, Neuro, and musculoskeletal system. Many nurses make the mistake of only documenting on the systems which were sited in the original referral (i.e., the patient is diagnosed with CHF, therefore you do not have to assess any other system. ) This is WRONG. You must assess all systems. Remember to do your supervisory visits for your LPNs and HHAs. LPNs every 30/60 days depending on Medicare/Medicaid guidelines. If HHA, every 14 days for Medicare and every 60 days for Medicaid. Document every time you call the MD. Make sure you write communication notes everytime you call anyone. The office may tell you they are writing the communication note; you write one also.

    Hopefully this will be helpful to you.
  10. by   wcnurse
    O/A all body systems means just what it says. to write this means that you have assessed all body systems. of course you will document any abnormal finding but one should also be sure to document any specific order whether there is an abnormalty or not. such as, If the 485 specifically states "assess for signs and symptoms of UTI, make sure to document, no s/s UTI, no burning urgency, urine clear without odor.
  11. by   CardioTrans
    Also, dont forget the progress towards your goals
  12. by   Nurse Candy
    Thank you everyone for all of your help, especially tburrell. All of them did help me quite a bit. I was actually told that my charting was improving after that. But now look what has happened:
    I am truly devastated right now. I would like to find some Christians who really do treat others as they would want to be treated. I have come to the conclusion that Christians, as well as nurses, "eat their young". I worked for an organization run by a local Baptist church.
    Today I have "lost" (they "let me quit") the home nursing job that I have only held since June 23. Was I a bad nurse? No! All of my patients loved me. My downfall was that !@#$%^&*()+! Medicare paperwork. I could not, for the life of me, get it all done in the time that it was supposed to be done in. It seemed like the requirements were always changing. I couldn't keep up. I bet even "normal" have this trouble. But, I have ADHD, and although I have an IQ of 120 and am quite smart, my reading and writing speed have always been abnormally slow.
    If I was there to affect the lives of my patients, why have I been taken away so soon? What does God have for me to do? Now?
    I have been very down and low and depressed for most of the day. Crying for most of it, too. Not only do I have ADHD, but also bipolar disorder and anxiety. I'm not in too great of shape right now.
    I sure could use some love and encouragement and advice and email right now.
    -------------------
    Candy, RN, BS
    @}-------}-------
  13. by   adaptation
    Your employer sounds stupid, stupid, stupid!

    With a nursing shortage and no one lining up to do home health care (at least not here), why on earth would they get rid of someone because of their documentation skills???

    Slow documentation never killed a patient, for G'ds sake!

    If you were as good as you say you are, and I believe you must be, or you wouldn't say it...why didn't they invest the time and effort in helping you "get with the program" vs. firing you? Do you have any recourse? Like up here in Canada, there is such a thing as "wrongful dismissal" and an employer would be in deep s--t financially and otherwise if the court decided you were not given enough coaching, support, etc. that you needed to do your job. Maybe you could see if there is such a thing and if it is worth pursuing. It might help restore your dignity.

    Take care of yourself. You know that if you don't, the bipolar stuff will raise its ugly head. Don't get stuck in the trap of self blame or beating yourself up. Life's too short; they were the morons, not you. Just remind yourself how much your patients liked you and what good care you gave. That's the most important thing at the end of the day.

    It's like being knocked down. You are a little worse for wear, but you have to get up again and get back into things that are good for you.

    Work is filled with enough struggles, inside and outside of us. Add more than the usual (like your charting) and that is a set-up for disaster!

    Maybe they have done you a favour. Just hold onto your self-esteem; no one can take that away.

    <sending you a very sympathetic hug>

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