wcnurse replied to Nurse Candy's topic in Home Health
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...
another classic example is the following. Under "topical med". I always put what topical if any that is ordered. Well, now, if the order states to apply with a Q-tip, you must state "applied with Q-tip". Also, if you used kerlix or kling, it must...
wcnurse replied to Nurse Candy's topic in Home Health
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 increa...
I have a cousin who got into la. tech fairly quickly for the clinical portion. You might want to look into this route although you may have to relocate to ruston.
I dont know if this is going on at other agencies but we are expecting accreditors to come back soon and they have given us new rules as to wound care notes. Under the blank "cleaned with" you must put what you patted dry with. If you used packing...