Charting at time of visit?

CapeCodMermaid, RN · Mar 22, 2007

Perhaps I'm not the best person to answer because I am new to HH and have only seen patients on my own for 4 days. But,here goes: I do my charting in the home simply because I am still 'on paper' and have to leave my note for the next nurse. I oriented with 2 other nurses. One did the visit, took notes on a paper and then went back to the office to chart on her computer. The other did the entire note with any new orders or communications right there at the time of the visit on the computer.

Our agency says the note must be completed by the end of the day or the next morning if you're swamped. They only 'communicate' via the computer once a day.

Best bet is to follow your agency's guidelines.

caliotter3 · Mar 28, 2007

The agencies that I worked for had time frames when the copies of the documentation were required to be in the office, typically 48 hrs after the visit. The field chart copy, (if there was one, one agency had one hard copy only), supposedly, was to be left in the field chart at the end of the visit. I was instructed by my preceptor during my home health rotation in school, that all charting, except for notes to self, should be done outside the home. I am aware of, and tell my clients, that the field chart copy is not necessarily the "final say", as we are always under the onus of being called in to our offices to complete and/or correct our documentation. One RN told me specifically that she was making copies of the charting for the clients for their personal use (they like to sue) at their request. Since clients have the opportunity to copy as well as read our charting, that is one of the reasons why I inform them that the field chart copy is not necessarily the "final" copy. I also inform them about the ownership of the field chart, as this issue has come up many times. It is now even stickier with new emphasis on HIPAA.

I have found some nurses remove all their documentation or don't put it into the field chart until just before the monthly supervisor visit. This is because they never get their charting done on time or else they literally do not want other nurses to have access to what they chart for their shifts. When I was being oriented one morning, we got a surprise call that the supervisor was coming, my nurse orienting me, dropped everything, (luckily we didn't have anything due for the pt at that time) and proceeded to write 6 days worth of notes in fear that the supervisor would notice that her charting was not in the field chart. I say, to each his own. I have worked 7 days a week, mulitiple shifts for more than one employer; I could not get away with that behavior. I read all charting by my colleagues. That is how I find out things that are not reported to me. If it isn't there, I notice it. Do I tell the supervisor? Only if a situation comes up where she corners me and I have no choice. The field chart is in the home for a purpose. If it is incomplete, then it doesn't serve the purpose for which it is left in the home.

DutchgirlRN, ASN, RN · Apr 2, 2007

It's not the "law", I don't know where they came up with that. We are allowed to do whatever works out best for us but have time limits as to when charting has to be done. 48 hours for reg visits, 4 days for eval visits. Since we're going pay per visit, starting tomorrow, I'm going to do my level best to get the majority of the charting done in the home on the computer. I don't like doing that because I feel the patient deserves all my attention but hey the agency caused this situation. If I don't first write everything down in my notebook perhaps it will save me some time. I don't like not having a paper record of all my visits but again the agency caused this situation. I gotta do what I can to not end up making $10 an hour.

Cattitude · Apr 2, 2007

I don't like doing that because I feel the patient deserves all my attention.

Up until now, I had not really been charting in the home but saving it until later and making notes as I talked to my pt.

I felt like you did, when I tried charting on my laptop, I was looking at the computer and NOT at the pt. It wasn't really fair to them. Some nurses did it my way and some did do it in the home.

BUT, I had a bad couple of weeks personally and managed to get myself really backed up with charting. So that is it for me. I am doing it in the home from now on. I will not go through this again, it is way too stressful.

I've been charting all weekend trying to catch up, NOT FUN.

DutchgirlRN, ASN, RN · Apr 2, 2007

I've been charting all weekend trying to catch up, NOT FUN.

:yeahthat: :yeahthat: :yeahthat: :yeahthat: :yeahthat: :yeahthat: :yeahthat:

Yep, especially when we're not getting paid to chart!!

justrubl · Apr 17, 2007

48 hours for reg visits, 4 days for eval visits.

That sounds really nice. The rule at my agency is 24 hours whether it is a regular visit or an oasis. They will give you 48 if you are really backed up (one day last week I did 5 oasis in one day) but the policy is 24 hours.

nursechris1 · Apr 17, 2007

My perspective is that the charting should be at least started before moving on to your next patient. I didn't always complete my charting in the home, but I at least turned on the computer and put vitals in, and anything else that I might forget if not documented right away. Sometimes I would go sit at the park and finish my note. I do expect my staff to get their documentation done within 24 hours. It's just more accurate if done sooner rather than later. Also, there have been times where a physician calls the office, or the pharmacy calls and needs information, and I can't give them the information because it isn't charted yet, and the nurse caring for the patient is not working that day.

CapeCodMermaid, RN · Apr 17, 2007

We do all our charting on computer. The information is transmitted to the main server in the middle of the night via phone line. So, for the doc or the next caregiver or whoever, it makes no difference if I chart at the pt's house at 9am or come home, have a cup of tea (or a shot of whiskey depending on how my day's gone....kidding) and do my charting at 6pm. They won't get the information till the next morning.

I write notes as I go and like that method better than sitting at the patient's house typing away.

justrubl · Apr 17, 2007

We are going to computer charting in the next 6 months but right now we are still using the paper oasis. I know the laptop is going to make things faster in some ways but I am not sure about how it is going to work.

CapeCodMermaid, RN · Apr 18, 2007

The program we use is pretty straight forward. All the information you need about your patient is right there...care plans, orders,med lists and of course the visit notes. It's set up so you can't finish and send unless everything that is supposed to be done actually is done. I've only been doing home care for 2 months and had to start out on paper. I find the computer to be faster and more efficient.

DutchgirlRN, ASN, RN · May 9, 2007

Today for the first time I did my admission charting in the home minus the Oasis and Narrative Note. It didn't take me any longer to go ahead and enter the meds instead of simply writting them down. When I got home I was done in a jiffy. I'm doing it again tomorrow.