Developing better Documentation to provide better care and protect my license

[IslandLPN88]

I am 24 y/o male,I have been an LPN for a couple years now,and I have been able to wing it with my decent observational skills and to be honest less then Par documentation skills. I know I provide high quality care,I would like my documentation to reflect that!?

Here's a summary of my clinical point of view and the tools I plan on using to develop better documentation skills,I'll try my best here,And then I would love to see some Input and feedback from more experienced nurses LVN/LPN's and if you are an RN,thank you for your input and please,keep in mind I'm working in my scope of practice.

I am currently a home health LPN,I do medicare nursing and private duty cases.

I have been sent to homes for woundcare,post total hip wound care,IV ABX,Post OP home care,Med setup/teaching,sitting,over seeing patients in hospital hired by family to make sure hospital nurses don't ignore or provide sub par care,client who is a level 2 on los ranchos coma scale,trached,ostomy,g-tube and cathetered. Diabetic management,ect.

I have done alot more at another facility but for now whats fresh in my mind is at this agency i have been working doing these sort of home health visits,and with alot less support from other nurses because I'm alone out in the field. I recently got an Iphone which I am very excited to start using as and integral part of my nursing process.

My understanding of the office I work for has been a challenge for me,maybe I'm a slow learner or they don't give grand tours when you get new jobs out of respect,figuring you already understand the whole providing Health care/skilled nursing/case management process? I don't know but this really has been a hit the ground running experience for me.

When I get a Medicare patient they send me an email or hand me a piece of paper with the clients info on it. Not much really,just there name,address,phone number,diagnoses and the skilled nursing that they need me to do.

I can go through the patients file back at the office but if I'm not in the area or they call me in quick that's all I get. That and maybe a nursing report.

I looked online for what I could do to know that I'm doing a better job,Like SBAR Situation

Background

Assessment

Recommendation

But upon looking around this is really better for what should be included in report.

Is there some more I could do to make my documentation more complete yet excessive.