New to PDN

[seijidan]

Hi everyone, so I passed the nclex a year ago but has been having a hard time getting hospital job due to lacking the 1-2 years of nursing experience requirement. I have been working as a PCA since January but just last week, started working as an independent PDN. I found the case through craiglist and to my surprise, they hired me. They just basically wanted a nurse to assist them with their mother's care. I'm very much new to this private duty nursing. My questions are, what exactly do I do? where do nurses notes go and where do I write them down and where do I submit them? what are other forms i need to do? I don't wanna sound stupid but I'm really at a lost right now. Any response would be appreciated :)

[caliotter3]

Unless there is some third party involvement, you do not need to do nurses notes at all if the family does not require them. One private duty family that I worked for had several caregivers coming and going, to there was a notebook to write a shift summary or anything important. Actually, it was nothing more than a standard communication book. In private duty, you basically do your duties the way the client explains that they want them done. As long as the client is pleased with your work, everything is ok. You might want to come up with some hint type documents for your own use. Start with a sheet of paper where you write down what gets done when, a daily schedule, so to speak. Put in routines, med administration times, etc. This daily schedule can be put into a thin binder or posted on the wall in an inconspicuous place. Another idea, is to write a list of the house rules. Helpful for those homes where the inhabitants are strict about what can and can't be done, like "no smoking indoors", etc. These papers are good to have for your own use in the beginning, and for anyone who might come in to fill in while you are on vacation, or out sick.

[seijidan]

I've read from the Medicaid package that proper documentation is required. I have written down nurses notes on a notebook but I have a feeling that that may not be enough. I've read from others that they only bring a notebook. The clients family didn't seem concerned at all about nurses notes/documentation of what I did or the patients status and they've had independent medicaid providers before.

[caliotter3]

Then you are working for a medicaid entity and not doing private duty for a private pay patient. Medicaid is the third party here, unless there is also an agency involved. You have to do what they tell you. Surprised that the client has not clued you in.

[seijidan]

Then you are working for a medicaid entity and not doing private duty for a private pay patient. Medicaid is the third party here, unless there is also an agency involved. You have to do what they tell you. Surprised that the client has not clued you in.

Sorry. Wrong choice of words.

"You have to do what they tell you" - you mean the client and her family?

Well, they weren't really specific about the things I should do other than attend to their mother's need. I'm just concerned about documentation. I don't want to have a problem with lack or insufficient documentation

[caliotter3]

If you are working a private duty case you will be taking direction from the patient or from the patient's family, who are your employers. If you work for an agency, you will take direction from the patient, patient's family, your nursing supervisor, and you will follow the plan of care as signed by the patient's doctor. Documentation is not necessary for a private duty case where no agency or third party payor is involved.

[seijidan]

Thanks for the responses. I'm not contracted with any agency nor is the client.

[HisTreasure, BSN, RN]

I've worked Medicaid cases before and like PP have said, a communication book is what some use. I was the primary on my last case and I'm in the process of opening a new one. In these instances, I treated the documentation like I would at an agency. I typed out the Meds and what diagnosis they were associated with. I typed out his initial "assessment" (fact-finding worksheet), and his therapy schedule. I requested specific names of each of the PROM exercises PT did with him so I could go out and find photos online with instructions. I placed all these in a binder with dividers. Then I kept a nursing journal that I requested all nurses document in every shift. The family didn't require it, but I knew that when it came time to recertify his hours all the supporting documentation would help him maintain eligibility or even increase his benefit. This of importance to the patient and the nurses who depend on the case for income! I've seen normally qualified kiddos lose hours because their condition was not properly documented on an ongoing basis. An examiner is looking at the here and now, when approving hours and sometimes the kid is stable at that time (from the great home care they receive!) but an examiner can't argue with six months of supporting documentation showing both the "good days" and the "bad days". Document, document, document, even in (especially in) PDN! JMHO.