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. Visit ksreuter profile page

    About ksreuter

    Joined: Aug '09; Posts: 23
    Director of Nurses - Home Health Agency
    Specialty: 4 year(s) of experience in Med/Surg, Perioperative, Home Health


  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.