Charting help

caliotter3 · May 13, 2015

Ask your supervisor to show you some examples of good charting. That is the easiest way to get the idea. Otherwise, make certain to address the items on the 485 and always include teaching. I've looked for examples online, but have never found much unless I've run across examples on this site. Those usually are slanted to a patient in an acute facility, but better than nothing.

happymama · May 15, 2015

Caliotter3 thanks for the advice. I will do that and I started looking on things online as well.

adreamdeferred, MSN, RN, APRN, NP · Jun 23, 2015

she said she wanted me to say why I am seeing that patient and work in my note why they still need home health services.

That's what was missing. In home care you have to justify why they still need skilled nursing in every note and the documentation should be able to stand alone. If someone randomly chooses to read one your notes it should not leave a lot of holes. Give a brief overview of why the pt is being seen, what skill was performed, any problems or coordination/communication with other members of the care team and what they still require or additional goals from plan of care that need to be addressed at future visits. There has to be a need for skilled care and all nursing skills including education fit that requirement. Does the pt not understand their medication or not take it properly? Do they have a new diagnosis such as diabetes, COPD, or recently started taking coumadin? Can they not perform their own wound care or lack a suitable caregiver? Also make sure you address what makes them home bound if this is a requirement of their insurance. These are some of the things that separate home health narrative notes from "regular" charting in other specialties. Don't get discouraged. Like Caliotter 3 said, look at some examples of good charting then you will get the hang of it. Best wishes.

toomuchbaloney · Jun 25, 2015

In my view, her request is for you to be including documentation which is describing progress toward goals. In other words, the patient is qualified for and receiving home health care for some very specific reasons. Once those reasons are resolved or the goals of care are met they must be discharged.

So, if you are there because the post op patient requires home PT, education, and a dressing change, your notes should reflect whether or not the patient continues to require that care and why or why not. It doesn't have to be rocket science, just the bare minimum facts which support either DC or ongoing care.

The best way to learn this well is to review examples of "good" documentation (as has been suggested).

In both home health and hospice, field nurses do themselves a favor, IMHO, if they utilize the POC to direct their documentation. That automatically makes the notes relevant, individual, and attractive to JC or CHaP or whichever group has certified your agency.

Good luck, sounds like you are well on your way to becoming a valuable professional in this area of care.

KelRN215, BSN, RN · Jun 29, 2015

Well, you know why you are seeing the patient and why they continue to need home nursing services, write that in your note.

Ex: "Pt seen for scheduled weekly methotrexate injection... narrative about visit... Parents remain unable to learn to administer injection, will plan to continue with weekly visits for safe methotrexate administration."

danarooo, BSN, RN · Jul 1, 2015

Always "paint a picture" of your visit, including the continuing home bound status and the continuing need for homecare because Medicare is picky and they are always looking for a reason to say "nope, not gonna pay". Like another person said, ask to see some good examples of the type of documentation your agency is looking for or ask your supervisor for any good "rules of thumb" to help guide your documentation.

Libby1987 · Jul 2, 2015

I've been reviewing notes the last couple of weeks, can't tell you how many I see documenting teaching or doing simple procedures as a skill with no indication of medical necessity.

ie

Teaching constipation mgmt but noting patient isn't constipated and having daily BM's. No note of recent constipation requiring an additional hospital day due to post op narcotics and lack of knowledge.

Relatively simple dressing changes .. Foam and transparent dressing with no note of edema, pain, on ATB tx, no update on wound progress.. Just a patient with findings WNL and a non complex dressing change.

When an insurance co requests clinical notes for authorization they're not going to give each note the benefit of the doubt based on the original clinical summary, each note needs to stand on its own demonstrating medical necessity and need for a SN to perform the service.

It doesn't require a novel but some findings/statement supporting the need for that particular visit.

Some insurances/services/conditions require more or less than others. You better have a good reason to be out there just to teach constipation mgmt while a wound vac dressing change on a complex wound for someone clearly stated as homebound is pretty much enough in itself (along with documentation of wound progress)