This question is for those of you who do visits.
You see your Mary every Friday. You go and do your visit that day and her BP is elevated, she's asymptomatic....you call the primary to let him know, BUT, he can't come to the phone so his nurse comes to the phone. You give her the necessary info and she tells you she will relay it to the primary and will call you back. Keep in mind that you complete your Skilled visit note for this client which you will turn in today as this is how you get paid. Okay, after the phone call, it's time to move on to your next visit. The cay comes to an end, you haven't heard from Mary's PMD. The following Monday He calls and doesn't feel her meds need to be changed or increased at this time, but he wants you to call in her BPs for the next month.
My question how do you document what happens in between your visits with the same client since you only see her once a week. A lot of things can happen in a week. You order refills and the pharmacy calls and tells you they need the doctors authorization etc. Plus, when you leave her home, there's no telling where you might be when the doctor calls back. I can't carry a big notebook in my purse although I know some people who do 8 hour shifts have a communication book so the next shift knows what is going on. But it doesn't work that way with visits, you are THE only nurse, but you need to document info so you can know whats going on when whoever calls you back, and to just cover yourself.
Love to hear what you use.
Sorry about my grammar
etc. kinda sleepy!