documentation in a group home

[RN 1975]

A former student of mine is responsible for 16 people living ain a group home. She needs to chart on these people on a routine basis and is looking for a simple form to use that covers their current problem, labs, procedures, follow up appointments.

[txredheadnurse, BSN, RN]

It sounds to me like your former student actually needs an overall tracking form in which he/she can list frequency of labs, appointments, quarterly reviews etc. For the actual charting of findings he/she can use a nursing/progress note. For an example in my state in the waiver programs governing group homes the nursing notes are combined with the Medicaid billing forms. We separate those nursing items that qualify to be billed in a time break down section and then a narrative note follows down below. We also use these same forms for narrative notes that don't meet the billing guidelines but are still necessary for documenting continuity of care, emergent or chronic issues.

Our quarterly reviews are one to two pages in which we summarize specific issues we are tracking (such as diabetes, mental health, hypertension, seizures, etc.) and if goals were met such as a reduction in weight or fasting blood glucose, etc. plus list all labs, appointments and assessments such as PT, OT or speech in that quarter.

To summarize a tracking form (I format mine by category like lab, psych appts, etc and then frequency (q month, qweekly etc). I then list all my clients under the areas that pertain to them. One can use an electronic format like outlook calendar or just go old school like I do and list everything in pencil so I can amend it very quickly. Otherwise I do all my nursing documentation on Excel spreadsheets. Hope that helps.