Returned documentation

  1. Anyone else about to pull your hair out? I am spending WAY too much time changing words, adding words, etc etc.....
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    About BabaLouRN

    Joined: Feb '06; Posts: 138; Likes: 37


  3. by   Libby1987
    Everyone feels that. Including the staff that have to review it, send it back, review it again. Often the same errors and omissions that are seen recurrently. That part of the job isn't fun for anyone.

    We're the only healthcare field where nurses are responsible for supporting reimbursement with documentation of their medically necessary skilled service at the same time needing to document for compliance and standards of care.

    I have kicked rocks many times myself but the reality is that nursing skill in documentation for the above is an essential part of working in home health. The requirements are learnable and you can minimize most of the corrections/completions if you question and really learn the reasons behind the expectations. Many nurses are overwhelmed with time mgmt and scheduling on top of learning their unique role and don't have anything left over to gain a deeper understanding of home health documentation. But I can't tell you from personal experience that it was time well spent in terms of both regaining lost time and promotion.

    I apologize if that comes across as too lecture-y but I know its possible to master it.
  4. by   AtHomeNurse
    Initially yes, now no. I make my notes as thourough as possible so reviewers have very little questions at this point. Initially it felt like I just couldn't get it right! What really helped is when they requested I change or fixed stuff I asked for an explanation why. It became a learning tool, now I don't make the same mistakes repeatedly, making my reviewers life easier and reducing corrections for me.

    In addition to what was said above, homecare, and especially oasis, have a language all their own. It's not like most other charting and getting it right is crucial. It can certainly be frustrating though!