QUESTION 1: How do you as a visiting nurse document between visits. For example, you go to your clients home and setup meds, you phone the doctor about a concern or question, you leave. An hour or hours later, the doctor calls with your answer or a med change etc. How do you document this since you have left the home and have probably done your documentation for that client for the day.
QUESTION 2: Your clients Primary calls and wants a medication increased or D/C'd. You are at the clients home and you need to set up meds. Do you set up the meds with the new verbal order and do a T.O. later for the doctor to sign or do you give the meds under the old orders until you get the new "written" orders from the doctor.
What is your agency's policy on these two questions.