Charting in HH

I can equate hh charting like doing a complete initial assessment each time, plus adding in all the teaching u have to chart. It is computerized by it still can be time consuming. I take about 30 min per patient to chart.

Charting in home health...hmmm the company I work for uses HomeCare HomeBase. The charting is really quite repetitive. We have to chart the whole assessment, address every intervention including ones that we are not teaching on at this time. Then we have to chart the goals regarding the interventions that we do teach on. Then, we are required to chart a narrative on each patient. Every narrative I write is a duplicate of the assessment, teaching done, diabetic foot checks, med changes, falls, care coordination, etc. Then, if we have to write a communication note to the doctor that is a separate note. If any VS are out of the set parameters, we have to address those as well. Then if we have any notes to send to the doctor, lab values, etc then we have to call the office and alert the staff to send that information on to the doctor. If I chart a visit after it is done. It can take me 20 minutes JUST to do the charting portion of the visit. So if I charted while I was seeing the pt, I may have 10 minutes of time that is dedicated to the pt. without me doing any charting.

The OASIS is a 15 page document which is required by Medicare for Home Care patients. It includes the medical, psychosocial and functional assessment of the patient. It needs to be completed on the first visit, anytime a patient returns from the hospital, on discharge and every 60 days. The questions can be very ambiguous and it is a learned skill to fill these out.

Documentation in home health is driven by regulatory requirements- of which there are a lot for home health. The OASIS is a comprehensive assessment that is required at the time points that the above poster mentioned. It is important because it drives payment and quality of care indicators that are publicly reported. And it also helps to formulate the plan of care for the patient.

At each home visit, the nurse has to demonstrate through the documentation what is being done for the patient, all the while justifying the continued need for skilled home health care and showing progress (or lack of) toward goals. The nurse also has the role of the case manager and is responsible for care coordination, so that adds additional documentation. I'm a surveyor so I've seen many different types of electronic medical record systems. IMO, none of them work all that well for home health. There is a push to move all agencies toward EMRs though. Although it does take a lot to get used to the documentation in general, home health nursing is very rewarding.

I honestly don't find the charting to be all that hard or time consuming. It's a lot easier than what I had to do when I worked in a SNF. Once you learn how to answer the OASIS questions and figure out the program, it's not that hard.

I am going into a part time HH position soon and while I understand the charting has changed a lot since I last worked HH (in the early-mid 90's) I feel like once I learn it (just like in the hospital) it the charting will become routine. My biggest concern is part time won't pay enough but I am not interested in going back to the hospital setting - at least not now.