CHARTING AND DOCUMENTATION help!

Remember that every single clinical note must stand alone; in other words, you should be painting a complete clinical picture every time you document. Your documentation of tasks such as wound care must echo your plan of care and should be in excruciating detail (cleanse w/___, apply___, cover w/___, secure w/___, aseptic technique). Remember to document any and all care coordination (communication with any member of the health care team, including caregivers, DME providers, physicians, clinical supervisors, etc., etc.). Always address progress (or lack of progress) toward goals as they are stated in the plan of care. Always make sure you are demonstrating homebound status, if applicable, and skilled need and medical necessity. Indicate why the pt continues to require HH services.

These are just some of the areas I do not see done well when I audit a record.

I often find that home health nurses forget to document a complete head-to-toe assessment with every visit. It doesn't matter if you've seen the patient 10x or 200x before- you still need to document the entire physical assessment. Also, if your patient has a urinary catheter or PICC line- you need to document the appropriate assessment of those items as well (18 fr cath, 10ml balloon; double lumen PICC in right upper extremity, etc.).

It is very important that you document your patient teaching appropriately as well. Indicate who you taught (pt or caregiver- and who the caregiver is) and the details of what you taught. If you use a standardized teaching tool and a copy is available in the chart or at the office for reference, it makes it easier to document because you can state, "Instructed pt on signs and symptoms of hypoglycemia via Prichard Hull teaching tool." However, if you don't have a standardized teaching tool, you should indicate what it is exactly that you taught (I.e., "Instructed pt on signs and symptoms of hypoglycemia, including hunger, dizziness, shakiness, sweating, anxiety, and weakness."). You should also indicate the patient/caregiver's response to your teaching. If the patient demonstrates or verbalizes complete understanding, you could choose to reinforce the teaching during your next visit or test the patient on their knowledge, but you shouldn't keep documenting that you are teaching the same thing. If the patient already has the knowledge, it does not support a need for continued skilled care.

Hi everyone, I am also a brand new nurse, and I just started doing home health, and I'm having a hard time charting and documenting. I graduated a while back, but I just recently passed my boards, and a hospital job is a little tough right now to get in, so I kinda landed in home health care. I even had to volunteer to shadow one of the nurses a few times, but she didn't really explain how to do it. Now I have all these 3 cases I opened last week and am still not able to complete my notes. Can anybody please help me? Can you guys send me some examples of comprehensive assessments and some follow-up visit notes? I would really appreciate it.

This is an example of a clinical summary for a SOC. Sorry about the caps, but I copied from a real assessment, and our system forces us to use caps.

THE PATIENT IS 78 Y/O FEMALE POST HOSPITALIZATION FOR EXAC OF COPD. INDEPENDENT PRIOR TO HOSPITAL PMH: COPD, CAD, HTN, ANEMIA, NIDDM. CURRENTLY, A&OX3, VITALS WNL. USES 2L/NC OXYGEN CONTINUOUSLY. DYSPNEA WITH MINIMAL EXERTION. LUNG SOUNDS DIMINISHED BILAT. NEW NEBULIZER AND RX FOR ALBUTEROL. ADMITS TO STRESS BLADDER INCONTINENCE. POSITIVE BS X4. SHE HAS A 0.5 X 0.5 X 0.2 CM WOUND (SKIN TEAR) ON HER RIGHT ANTERIOR FOREARM. POSSIBLE TAPE BURN. THE WOUND BED IS BRIGHT PINK WITH NO DRAINAGE. BANDAID APPLIED. FBS 110 TODAY AND COMPLIANT WITH GLUCOMETER AND 1800 ADA DIET.EDEMA: 2+ PEDAL BILATERAL, LEFT INSTEP 28CM, RIGHT INSTEP 26CM. RATES PAIN 2/10 IN THE BACK DUE TO ARTHRITIS. UNSTEADY GAIT, USES WALKER. INDEPENDENT WITH ADLS EXCEPT BATHING. LIVES WITH HER BROTHER, WHO IS THE MAIN CAREGIVER. PLAN TO TEACH COPD DISEASE PROCESS AND MANAGEMENT; TEACH MEDICATIONS, SAFETY, NEBULIZER, AND HOW TO DECREASE EDEMA. MONITOR WOUND.

Basically, you need to write the story. What were they in the hospital for? Medical HX? and then go through this list. I usually chart by exception, meaning that if I didn't mention it, it does not pertain to or is normal. I added normals to this example so you could see how it's done. All of this assessment data is in the OASIS anyway, but most agencies want you to write a narrative. I might have missed something, but this is the basics. Hope it helps.

• Orientation
• Vitals
• Lungs
• Oxygen
• Exertion level
• Bladder/bowel
• Wounds
• Pain
• Edema
• FBS if diabetic
• Diet
• Ambulation
• Assistive devices
• ADLS
• Support system/CG
• New meds (coumadin, insulin)
• New DME or equipment

You could think of your documentation as a written report on the patient. That way, anyone who comes behind you will have a good picture of the patient before seeing them.