Charting Question - Help!

Editorial Team / Admin · Aug 13, 2005

I'm new, wore out and have a question.
The home health place I work went to computers in the last year, ..with the intention of us using them in the home. Changes have now occured which do not allow us to leave the office with the laptops (no field priveleges - to costly). So we are now trying to see a full load of Pt's (finances also under staffing us) , writing notes down on scraps of paper and entering this info when we have time. This has now became a period of 1 - 2 weeks (sometimes longer) after the pt is assessed or admitted before it's entered into the computer.
Our supervisory is assuring us "it's fine", of course she's never done it or had to do it.
As far as entering documentation when it's electronic, what is the rules? Do you know anyplace I could find this info.?
Tks.

Electronic charting (documentation) is no different than written. You may have a different format......flow sheets and other items on the software, but, you still cover the same things as in the written word. All becomes the medical record the same.

whatwasithinking · Aug 13, 2005

Yes , I know. But isn't there an expected time documentation should be completed and entered ? I was taught "as soon as possible", but how long is pushing it? Am I making a big deal of this?

Editorial Team / Admin · Aug 13, 2005

Yes , I know. But isn't there an expected time documentation should be completed and entered ? I was taught "as soon as possible", but how long is pushing it? Am I making a big deal of this?

Now that is a good question. Do you work in a Home Health that is associated with the hospital? If so, find out when documentation is required in the medical record.

Some institutions that utilize documentation by dictation have to wait until the dictation is transcribed and no way to get on charts for days at a time.

You just need to find out what the policy is in your facility. I agree, 2 weeks is a long time to wait to document day to day changes in a physical assessment and/or procedures.

pricklypear · Aug 13, 2005

Our general rule is no longer than 24 hours. But that is in a hospital setting. You might try posting this in the home health section, they may be more familiar with time expectations in that field. BTW, what a pain in the patootie for you!! They made your job 10 times harder by going computerized if they won't let you take the laptop out of the office. I've got a friend who does home health with computerized documentation, and they take theirs everywhere. Good luck!