Counting breathing treatment days/min's

[dianediane90]

Having trouble justifying counting breathing tx min/days on MDS. The nurses give the tx's but lack documentation at times in nurses notes before and after tx given. They do put the min/days on MAR. One nurse says we shouldn't count if the documentation isn't there. Especially on residents that have them routine--they rarely put nurses note in on that. Any opinions????

[Talino]

One nurse says we shouldn't count if the documentation isn't there.

Correct!

Before we go further, do the staff nurses meet the definition of a "trained respiratory nurse"?

"Respiratory therapy services include coughing, deep breathing, heated nebulizers, aerosol treatments, assessing breath sounds and mechanical ventilation, etc., which must be provided by a respiratory therapist or trained respiratory nurse. A respiratory nurse must be proficient in the modalities listed above either through formal nursing or specific training and may deliver these modalities as allowed under the state Nurse Practice Act and under applicable state laws” - Nothing found for Mdscentral 2013 01 Ask-the-expert-respiratory-therapy-services #sthash L5BZLO3N Dpuf

[4boysmama]

we use PCC at my facility, and have a supplementary section where the nurse is required to document the minutes before s/he can save and scan the med as administered. Are you eMAR or paper?

[dianediane90]

We have counted min/days in past(on paper MAR) but feel uncomfortable as the documentation is lacking before and after tx. Some nurses are better than others at documentation but not consistent. We do have PCC but we are not E MAR yet. They have talked about it but thats it.

[CapeCodMermaid, RN]

We use Matrix and have the EMAR set up so the nurses have to document the number of minutes and lung sounds pre and post treatment.

[NurseMellie]

Documentation may be easy to come across with the skilled documentation since most of the notes include lung sounds, o2 etc. There is a big push atleast in my area to include the respiratory minutes since so many of our residents have COPD or other illnesses. We are working towards having the documentation in the EMAR, we use PCC as well. I'd imagine that there are going to be multiple orders in place that go along with the respiratory section, not just minutes

[sallyrnrrt, ADN, RN]

well i play on both sides of the "fence"

being a RRT & RN, have founs ir necessary to provide nurses inservices....related to doccumenting, tim in mins., pre and posr tx...etc seems adequate to satisfy CMS demands .