Charting for Home Health Pediatric Patient

[chickengirl1977]

Hi! I am currently working for a HH agency that deals with pediatric patients. I have worked for them for 8 months. I consider myself to be a "new" nurse as I have only been practicing since November 2011. I am with the same patient on a full time basis. My patient is medically stable, but at risk. His primary caregivers are wonderful but are his grandparents so there is the mom and dad that are divorced involved as well. I'm needing advice on my charting, etc. My patient is 7 and has state and federal agencies that are involved in his care who are stating they want more charting. I chart every 2 hours as required, but also when we do walks etc. I do not chart his every move, and he is an active little boy. But apparently they feel that all he does is sit around watching TV and playing games. Any advice I can get on charting would be appreciated!!! Thanks in advance!

[DidiRN]

Moved to Private Duty Nursing for best response.

[ventmommy]

Do you go to school with him?

What is his diagnosis? What things are you doing to care for that diagnosis?

[SDALPN]

Hi! I am currently working for a HH agency that deals with pediatric patients. I have worked for them for 8 months. I consider myself to be a "new" nurse as I have only been practicing since November 2011. I am with the same patient on a full time basis. My patient is medically stable but at risk. His primary caregivers are wonderful but are his grandparents so there is the mom and dad that are divorced involved as well. I'm needing advice on my charting, etc. My patient is 7 and has state and federal agencies that are involved in his care who are stating they want more charting. I chart every 2 hours as required, but also when we do walks etc. I do not chart his every move, and he is an active little boy. But apparently they feel that all he does is sit around watching TV and playing games. Any advice I can get on charting would be appreciated!!! Thanks in advance![/quote']

Without seeing the 485 or other details its hard to be specific. But every two hours is the least amt of charting allowed by medicare/medicaid. You would benefit from a documentation class...better if the class is specific to PDN.

My notes always start with received report from.... Then I document what I observe walking in. That includes what is/isn't connected to the pt. I document that the emergency equipment is checked and functioning properly. After that, I do my assessment. The assessment is supposed to be done in the first 30 min according to medicare/medicaid. Then that is documented. I document meds/feeds given and if the tube flushes easily (to document patency and placement checked). Any diaper changes and if it is urine or BM. I include color, odor, quantity, etc as it applies. I document that the skin is intact or whatever applies. AM care is documented. I document activities throughout the day. My favorite note that always sounds great is "developmental play encouraged" and insert therapy "____ therapy exercises reinforced per therapist instruction". I document changes. If the pt requires sxn, its required to document each sxn. My sxn note (change words as it applies to pt) sxn x2 for lrg amt of thin, white secretions from trach. O2 sat ^ to 99% after sxn. I document transfer to wherever the pt goes or moves to. The nursing hours are decided on based on the number of skills done in a time period plus the pts diagnosis/condition. At the end of my shift I document to cover myself. I write NAD. VSS. Trach midline, patent, ties secure per agency policy. Resp even, unlabored. O2 sat 100% (or whatever it is). Pox probe on left foot. GT patent. Diaper dry. Denies pain. End of shift tasks completed. Equip plugged in, charged, and working properly. Emergency equip at bedside. O2 tank full. Report given to...., who assumed care.

You can also ask your boss for an example so you can see how it should be done. National agencies usually give you am example when you have orientation. Look at the other nurses notes and compare. The other nurses may or may not be charting correctly, but you will get the idea. I hope that helps! :-)

[systoly]

chart any assessments, observation and intervention

everything that pertains to the DX, the plan of care (485) and

the reason/need for you being there

in addition, address developmental skills and any stimulation, activity

such as cause and effect

you can chart on any equipment cleaning/maintenance

and teaching is a favorite among the agencies

chart any and all teaching

[PerfectlyPlump, ADN, RN]

I have had some parents who think nurses chart too much, including me. Two have said so, and another made it as difficult as she could. (No table, no time. Here, fold these clothes instead....! )

It was ludicrous, and I ignored their "preference" in this matter. LOL

[SDALPN]

I have had some parents who think nurses chart too much, including me. Two have said so, and another made it as difficult as she could. (No table, no time. Here, fold these clothes instead....! )

It was ludicrous, and I ignored their "preference" in this matter. LOL

I remind those parents that our charting is how they get their hours. Usually those parents are the ones that are sue happy and know the less you chart, the easier it is to burn you. But I avoid those parents if I can.

[enuf_already]

Think of charting as justifying why you are there and why this child needs nursing care. Don't forget to include assessing, teaching, and responses to interventions including pain assessments. If the child has a monitor always include that you have checked settings, battery or power source, and the alarm is on and audible. Although that might seem trivial, I assure you it is not.

If families don't like the amount of time it takes to document, remind them that your charting can help to justify they need nursing hours--or incorrectly appear that they don't.

[SDALPN]

Oh yeah, I will add that I document when the parents are attentive to the patient. Great for cases where there are questions about the parents involvement or if something comes up in the future. You can remind the parents that you are also documenting to help them.

[smartnurse1982]

Are you guys using assessment sheets also?I keep getting told there isn't a reason to write all that when there are checkboxes.As a matter of fact,the supervisor said its really not neccessary to write beyond the 5 lines they give us on the combined assessment sheet/nursing notes.

[SDALPN]

Are you guys using assessment sheets also?I keep getting told there isn't a reason to write all that when there are checkboxes.As a matter of factthe supervisor said its really not neccessary to write beyond the 5 lines they give us on the combined assessment sheet/nursing notes.[/quote']

Wow. I had an agency tell us to fill out the assessment and in the notes just put "uneventful, routine shift"....I never did it. Agency was shut down and nurses were charged with fraud for multiple reasons.

You should be charting in detail, that doesn't mean double charting though. Medicaid/medicare have requirements for charting. That's the minimum standard. If your agency is accredited by CHAP, JCAHO, etc, you may have further requirements...but that is *if*.

I hate charting and make it an art to write as little as I can. But I put a lot of info in few words and use as many approved abbreviations as I can. But there is no way 5 lines is enough for 8 hours on even a sleeping child.

[mluvsgnc]

You said that the pt. is perceived as "watching tv and playing games all day," so chart his activities and how he tolerated it. For example,

"pt. physically active AEB (insert activity- running from room to room in house or riding bicycle for 30 minutes or doing cartwheels around room or whatever). Pt. tolerated activity and was observed laughing or pt. stated he was "having fun" or whatever. Heart rate is WNL for patient or no observation of respiratory distress or whatever."

Without a diagnosis to go off of, it's hard to tailor an example, but you get the idea