Charting for Home Health Pediatric Patient

Specialties Private Duty

Published

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!

How would you chart a pt that has aw/as cycles"activity"?One post in particular got me thinking,because well,sleep is subjective...and objective at the same time. Slowed respirations,hr decrease,easily to arouse,etcThis has come up on this forum before,but lots of agencies don't want activity charted,but I'm not sure why.

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Specializes in Complex pedi to LTC/SA & now a manager.

Patient resting quietly eyes closed, respirations equal & unlabored no s/s discomfort, distress, or seizure activity observed at this time. Responsive to light touch or verbal stimulus. Posture relaxed. VS WNL.

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Specializes in Peds(PICU, NICU float), PDN, ICU.

Sleep = resting with eyes closed. Can add things like...Resp even, unlabored....HR WNL...0 distress noted...0 s&s of pain observed...acyanotic, skin pink, warm, dry....

I alternate resting with eyes closed with one of the "additions" so I'm not charting the same thing over and over and so I cover a few assessment items.

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Specializes in HOME HEALTH, Rehab, Hospice, Med Surg.

I need the same advice. Did you find your answer? I still chart every two hours but add assessment on skilled nursing form

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Specializes in MS, PEDI.

Who is your agency????

Your agency should be providing better support.

As you have time, call the insurance company and get SPECIFIC details on EXACTLY what they want included in charting.

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