Documentation woes


  • Specializes in Home Health, Urology, Clinical Trials. Has 21 years experience.

After fifteen years of HH nursing and over 20 years nsg experience, I was offered a job as a QA nurse at a home health agency. When in the field, I did complete assessments and documented fully. As QA nurse, now, I find I am the only nurse in the agency that documents the apical and radial pulse. I also documented BM every visit and other items on the nurse notes. The nurses of this agency are fighting me on having to listen and document an apical HR. I argue how can you document that you did a cardiovascular assessment if you didn't get an apical HR? I am told that no other agencies request an apical HR. I never heard of this, but, brother these nurses are totally resisting improving their documentation. they never had a QA nurse before. So tell me, please, am I overreaching in requesting that the nurses get an apical rate?

JustBeachyNurse, LPN

1 Article; 13,952 Posts

Specializes in Complex pedi to LTC/SA & now a manager. Has 13 years experience.

Is this traditional home health or shift/private duty. I work one PDN agency and one combo agency. Both require apical pulses. Radial pulse is for quality& presence but not primary source of heart rate. Both (pediatric & young adult) require 1 minute counts for apical & respiratory rates yet some nurses are doing 15 or 30 second count. Then again yesterday I had a nurse that didn't think lung sounds & bowel sounds were part of a basic assessment and the patient has a respiratory diagnosis and recent abdominal surgery!

I know the two hospital based skilled home health agencies in my area require apical pulses in addition to full skin assessments


5 Posts

We're not required to take apical pulse. It says under VS on the oasis how you assessed the HR, radial or apical. I always do apical. With the older generation it's hard to feel a radial pulse at times.


104 Posts

Specializes in ICU/CCU, Home Health, Case Management. Has 35 years experience.

I do Apical, too.


91 Posts

I hope you find the standard and rationale in the literature. That is the way to go about it. A stron willed nurse needs more than say so to change practice.