documenting progress to goals

[KatieRN1121]

i'm working with a new company (home health Medicare certified) and i'm doing chart review. I'm finding alot of nurse writing "ongoing" for progress towards goals...what are you finding you are putting in this area?

[JustBeachyNurse, LPN]

i'm working with a new company (home health Medicare certified) and i'm doing chart review. I'm finding alot of nurse writing "ongoing" for progress towards goals...what are you finding you are putting in this area?

That's better than the ones that just transcribe the goal such as "client wound will measure 2cm x 5cm with no s/s infection by the end of 4 weeks". Or "client will tolerate full volume enteral feeds with minimal residual by then end of 4 weeks"

I was taught to document findings such as "current wound measurement is 3cm x 6cm, no drainage, no edema, no warmth, no erythema, edges are beginning to approximate. "

[Libby1987]

Simple examples..

The actual goals are..Wound closed. No s/s infection. Competent in wound care.

We document progress specifically but in general terms ie their level of understanding and ability to return demo.. 50% 100%

Wounds are measurements and descriptions... 100% slough now 50% center of wound sort of thing

Pain is at an acceptable level to patient at 3/10

our EMR has minimal, moderate progress, goal attained with current tx, goal attained/problem resolved.

We have both check boxes and comment section.

We don't include time frames, we can't control when a wound will heal.