Documentation woes

Specialties Home Health


Specializes in Home Health, Urology, Clinical Trials.

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?

Specializes in Complex pedi to LTC/SA & now a manager.

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

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.

Specializes in ICU/CCU, Home Health, Case Management.

I do Apical, too.

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.

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