Documentation Nightmare

  1. I'm the DON for a home health agency and I'm preparing to have a parent-branch meeting with all the nurses that work for our agency.

    I am new to the position and since I started I've been horrified with some of the documentation that SEASONED NURSES are turning in. One of my most horrific examples is "...I will not make that mistake again." IN A PATIENT CHART!!!!!!!!!

    Anyway...I'm trying to put together a session on documentation for the meeting. Any suggestions or resources out there anyone can point me to to guide me in this problem?

    Thanks much
  2. 1 Comments

  3. by   DixieRedHead
    Good grief! I cannot even imagine. The only advice I can give is that charting is always patient centered. It must be something that was said, observed, seen, touched, or heard, and what was done to address it. I know that is short but you are apparently starting from rock bottom.