Published Apr 6, 2005
FocusRN
868 Posts
Does anyone have some basic HHC charts, or sites with charts. My definition o f is basic in something with vitals, i&o's, feeding, linen changes, and meds. The adency that I will be working for says that their charting is a part of the patients file, so after I turn it in I won't have access to it, and I can't make copies, so I want my own, ya know just in case something comes up, and I need to back myself up, with my own documentaion.
Thanks.
1angie
16 Posts
Does anyone have some basic HHC charts, or sites with charts. My definition o f is basic in something with vitals, i&o's, feeding, linen changes, and meds. The adency that I will be working for says that their charting is a part of the patients file, so after I turn it in I won't have access to it, and I can't make copies, so I want my own, ya know just in case something comes up, and I need to back myself up, with my own documentaion.Thanks.
I have been looking also and have had no luck. If you find any good sites to obtain these, please let me know.
Thanks
renerian, BSN, RN
5,693 Posts
I am trying to understand exactly what your looking for? Do you mean a travel chart while you are working and caring for a client or keeping documentation to protect you at some later point in time?
renerian
Fiona59
8,343 Posts
My first thought was privacy act violation -- keeping duplicate charts at home.
What's wrong with keeping just a record of patient ID numbers in a day timer? Or do you think an agency is going to change your charting?
I am trying to understand exactly what your looking for? Do you mean a travel chart while you are working and caring for a client or keeping documentation to protect you at some later point in time? renerian
I am looking for Documentaion charts. I am a Medical Assistant and I do private in home caregiving. I am currently working with a SCI patient who recently was released from the VA in Seattle after he was struck by a car while riding his motorcyle last year. I made up a Spinal Cord Injury Handbook for this client with informational subjects for SCI's. And in it I have a section where i documents his I/O's, vitals, medication log, etc.. I am very carefull about recording everything !! The only thing I could find on the internet were I/O sheets and treatment planners. Stuff like that, but no good client documentation sheets. I just want plain ol' charting sheets. Nothing fancy. I guess I could just make my own up with "Works". Just thought I would ask anyway. I work 6 days a week plus i went back to school a couple months ago to work toward Bachelors in Science and also working towards Surgical Technology degree. I am so tired most the time I don't have it in me to do massive serches on something so minor. I have been using notebook paper, and wanted something a little more professional looking. Thank you for you reply !!! :
I think I gotcha now. I always make my own flow sheets on excel anywhere I have ever worked. Are you working agency on a private pay patient or as a privately hired caregiver? If your privately hired I wanted to be sure you were carrying enough malpractice insurance.
I think I gotcha now. I always make my own flow sheets on excel anywhere I have ever worked. Are you working agency on a private pay patient or as a privately hired caregiver? If your privately hired I wanted to be sure you were carrying enough malpractice insurance.renerian
Yeah, basically a flow sheet. I tried to do it with Excel but I suck at that.
My first thought was privacy act violation -- keeping duplicate charts at home.What's wrong with keeping just a record of patient ID numbers in a day timer? Or do you think an agency is going to change your charting?
The only personal info I would need is something identifying , and a list of was was performed at what time, any problems that they complained of, and that is basically it. I am not sure if the agency would try to change my charting, but the AMA, the two office RN's, and the director truthfully are a little shiesty. I just want to be covered no matter what.
Unfortunately you cannot keep anything pertaining to the client-it is against hippa. Sorry.
Isn't your agency providing you with the needed paperwork?
Unfortunately you cannot keep anything pertaining to the client-it is against hippa. Sorry.Isn't your agency providing you with the needed paperwork?renerian
I dont' work for an agency. I am self employed. Thanks anyway. I will make up
my own. And they are not for me to smuggle home a patients records. They are for me to keep daily records of activities and record vitals, bowel movements,I/O's, etc... I design and put together folders pertaining to individual clients needs and cicumstances. In this folder i keep a daily record of everything done with that client. Pretty smart, huh?!!
I dont' work for an agency. I am self employed. Thanks anyway. I will make upmy own. And they are not for me to smuggle home a patients records. They are for me to keep daily records of activities and record vitals, bowel movements,I/O's, etc... I design and put together folders pertaining to individual clients needs and cicumstances. In this folder i keep a daily record of everything done with that client. Pretty smart, huh?!!
You are sounding either like you worry to much , or you are to suspicous. Don't you frett little one. I have plenty of insurance.
Sorry I did not mean smuggling records.
ren