Charting in the home

Specialties Home Health

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Is it a jhaco (sp?) Standard to get as much charting in the home done?

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No but documenting at point of service is an industry standard for accuracy and efficiency.

It's still a hard fought battle as it is common practice to put it off until the end of the day. Home Health has a reputation for having to chart into the night, yet clinicians have a hard time building the habit. A lot of reasons are given but it comes down to habit and routine.

JCAHO

https://www.jointcommission.org/standards_information/jcfaq.aspx?ProgramId=6&ChapterId=0&IsFeatured=False&IsNew=False&Keyword=

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Hi Libby1987,

I'm newish to HH and I've finally begun charting my follow-up visits in the home. It's amazing what a time saver that is at the end of the day. I'm wondering how feasible it is to chart a SOC/ROC/Recert/DC in the home. Any tips for making those lengthier assessments more manageable? I've received a lot of valuable tips and tricks from your replies to various posts!

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Glad to hear it's helping!

For charting SOCs etc, it depends on the patient/home situation. For those who would enjoy your quiet company and allow you to concentrate, it can be mutually beneficial. I've sat many times in the home completing SOC documentation while the caregiver runs to the store. For those who are distracted/exerted by the visit or the home setting isn't conducive, it's better to chart at an alternate secure site on the way but before going to next visit.

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The prospect of coming home at the end of the day with nothing or very little to chart makes me giddy :)

When I'm scheduling patients I've started to allot some time for charting. For example for a follow up I'll allot 30min for the visit and 10 min to finish up charting in my car before moving on.

For SOCs I usually spend 1hour in the home doing my assessment, med rec and collecting data for Oasis(I have a cheat sheet). It then takes me about an hour to complete the Oasis plus a comm note for the schedulers. So would you block out two hours before scheduling your next patient so that the bulk is done in the home or somewhere nearby (depending on the pt/environment)?

Over time, do you think my SOCs will get faster or is 2hours reasonable? If you have any tips at all about streamlining SOC's I'm all ears :)

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The prospect of coming home at the end of the day with nothing or very little to chart makes me giddy :)

When I'm scheduling patients I've started to allot some time for charting. For example for a follow up I'll allot 30min for the visit and 10 min to finish up charting in my car before moving on.

For SOCs I usually spend 1hour in the home doing my assessment, med rec and collecting data for Oasis(I have a cheat sheet). It then takes me about an hour to complete the Oasis plus a comm note for the schedulers. So would you block out two hours before scheduling your next patient so that the bulk is done in the home or somewhere nearby (depending on the pt/environment)?

Over time, do you think my SOCs will get faster or is 2hours reasonable? If you have any tips at all about streamlining SOC's I'm all ears :)

Anything faster than 2 hrs for a SOC visit, documentation and follow up is not thorough. I can be very quick but even a straightforward TKR will take min 45 in the home. Anything with medical, treatment, psychosocial, disorganized meds and/or multiple teaching to manage should take 1.5 hrs if you're thorough and not missing needs that can or should be addressed at SOC. I believe strongly and in my practice I did things on the front end. 2 thorough back to back visits at SOC and you've established a strong foundation that you or other nurses can easily follow and care stays on track.

I've known many nurses new to HH that make 1 hr or less SOC visits and they didn't realize what they were missing. I don't mean within the basic requirements of the admission visit but the extra needs and risks with the patient and their situation that an experienced/motivated nurse will pick up on and address either at the visit or within their care plan.

That sounds pretty preachy but not intended to.

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Documenting in a patient's home is always ideal however this must be done in a case by case basis, some patients simply do not want you in their home for an hour plus and at times feel like its an intrusion. I respect that. If its not possible I try to document as much as possible in my car, right after the visit.

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Specializes in Surgical Specialty Clinic - Ambulatory Care.

That's assuming there is someone around to show/tell the newbie what they are missing. I have to say that I like home health better than any other nursing I've attempted, but the orientation and education for it SUCKS...mostly because it is non existent. I am a hospital experienced nurse...I understand a lot about procedures, and since I did ER I know mostly how to stabilize a patient. Home health has an entirely different skill set, that, after 9 months into it, I still haven't been able to grasp the full picture of. All the advice from my co workers is too general, like " We care for the entire person. You need to look for all their needs." Really? Can you be more cryptic? It really isn't just a problem in Home Health alone...all of nursing has this issue that a "a nurse is a nurse, no matter where he/she is." Well, not really, what one is looking at to prevent, educate the patient on, how one documents, and find resources for really does vary greatly between nursing fields...and facilities for that matter, but home health has been the most difficult in the fact that I can take someone in to my patients' room for a second opinion and advice.

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For me, it truly depends upon the client and your ability to concentrate. I personally, have been a home health patient before becoming a home health nurse, and it is very awkward to have a nurse just sitting there staring at her device typing away. As a nurse, I have noticed that it makes some of my clients uneasy as well.. when you are charting, unless you are very, VERY good at multi tasking, your not speaking to the client and staring at your computer screen... Some clients I have though, enjoy my presence and I enjoy their's and I have no issues in charting my visits while in the home. This is where, as a home health nurse, your powers of observation and your ability to to be efficient come into play. If you can read the client correctly, it can make everyone's job much easier. I have taken complaints from clients about other nurses before, and the majority of them state that the nurse was "impersonal" and didnt interact much because they were too busy staring at the device or computer. As we all know in Home Health, if we make the client angry or upset about something, it makes everyone else's job much harder and you set yourself up for the client to be "non-compliant" with plans of care. If its an easy visit with no issues, I will usually chart my narrative out in the car immediately after my visit, if there is alot of concerns to be addressed, I may just type a quick note regarding my findings for easy access, and just incomplete it until I can gather my thoughts for charting later, especially if I need to message docs or other clinicians regarding the client and I am needing feedback.

While it may be "better" to chart IN a visit, ultimately, the client is the variable. What is best for them at that moment. Being flexible is a key element to be successful as a home health nurse, IMO.

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