Charting question for Home Health Nurses

[jennilea]

I am an LPN with many years of experience, mostly LTC. For the past year I have been doing Home Health nursing as an independent contractor. I have noticed that some nurses are charting every single thing they do t/o the shift. Is this the norm for this field?

When I write my nursing note I do not include what I feel are trivial details: "Applied socks to pt's feet, then applied sneakers to pt's feet. Tied sneakers". Nor do I chart what I feel are obvious parts of a routine. For example, I would chart: "Patient assisted to shower chair, shower given, then assisted back to w/c"; whereas some coworkers chart out every detail- "pt assisted to bathroom. Shirt removed. Pt stood up, then stepped and pivoted to shower chair. Pants and brief pulled down. Pt sat on shower chair. Pants and brief removed..." I am sure you get where I am going with this. I give a narrative of the ADL's and save my detailed charting for the actual nursing tasks I perform: meds, treatments, TF, ect....

My understanding is that we are supposed to be documenting enough to validate the care being paid for and at the same time covering our butts should anything we do ever be called into question.

I would appreciate any input on this topic from other nurses as to what they are documenting on.

Thank you!

[Sharon Stephenson]

You are correct in your idea of how to chart your nursing notes. I have > 15 yrs in home health nursing, both as an LVN and RN. Actually, the more you write, the more you have to explain. QA depts will sometimes have you rewrite a note like you described, in my experience. A good nursing note gives data, action, response, and evaluation.

I hope you enjoy your home health experience as much as I did!

[KelRN215, BSN, RN]

You want to be detailed about nursing interventions- stuff that's going to affect how many hours the patient qualifies for when they are re-evaluated by their insurer/Medicaid. ADLs don't need to be documented in the detail that you describe, just make sure it is documented that the patient is dependent for ADLs and what was done. No one cares that it took 43 steps to get the patient to the bathroom.

[caliotter3]

Agree with the others. This topic came up with my supervisors over another nurse that was charting the 43 steps. The supervisor reinforced the correct way to do it, while stating that the other nurse was overdoing it and actually leaving themselves open to question, should there be 44 steps instead of 43. I have seen this a few times. What is really interesting is when someone charts these 43 steps to leave a patient clean, dry, and comfortable, and you encounter incontinence or feeding infusing into the bed that obviously did not start as you walked through the door.

[jennilea]

Lol thanks guys! Wondered if I was going crazy here!

These girls are documenting that they washed breakfast dishes, rinsed washclothes, put earrings on, ect... One LPN who actually charts that she gives an assesment every morning! Meanwhile, patient experiences out of the ordinary medical issues and all that gets charted is "Pt experienced episode of passing out. Placed back to bed. Left in care of mother". Not "syncope", no vs, absolutely no other details!!! But, hey, at least she picked out her earrings and got her hair braided that day!

We also had an issue with an incontinence rash that went on for 6 weeks, with each nurse putting different assortment of creams, ointments, and powders with no consistancy to the tx, other than they were all HOTPACKING a diaper rash! I stuck with Calmoseptine, came in one night and one of these girls actually left me a note that I needed to be hotpacking the area and putting TAO on it and not Calmo!!!! Went to the mom on that one but mostly I just come in, read these ridiculous notes, roll my eyes and wonder if I have finally become that cynical old nurse I never wanted to be, lol.

[caliotter3]

You have a big problem with the multitude of ways to deal with the diaper rash. First of all, proper hygiene and preventive measures should be a priority with all caregivers. Next: what does the 485 say? What is prescribed for redness, irritation in the perineal area? Anything? All of those methods? What does the doctor have to say? Get where I am going with this? Someone needs to obtain a valid supplemental order to put a treatment protocol in place, to include the topical medication to be used. That medication/treatment protocol needs to be added to your treatment sheet (or MAR, depending on how your agency records topical treatment meds). Then all nurses will be following the same order, and at some point in time, the rash will resolve, or one of the nurses will communicate with the doctor to change the protocol until something works. Your current chaos is not helping the patient.