Exactly how specific ?

I'm not sure about how the hospital nurses chart. I haven't worked in the hospital for 11 years. But you are right about home care. That is the expectation. This is where computers come in handy. I would type these type of things once and cut and past them into the documents as needed. It saved me so much time.

HHA's are getting increasing ADR's/denial of payments because charting is vague. We had one denied for "provided instruction in pressure relief techniques". they wanted to know specifically what was taught, some are asking us to document what teaching methods were used as well. I feel your pain, they're getting so picky!

cut and paste it is then !!

picky is an understatement.....but there is no real clear expectation of what it takes to satisfy medicare....bc never know who will being doing the judging........there are the ZPICS, RACS, MACS, And any other hurdles they may come up with.

its ridiculous that on patients who have a lot going on such as picc lines, drains, dressing changes, new meds, home health aide services, just one 45 minute visit can result in over another half hour of documentation. and god forbid the nurse forgot to document that they allowed the alcohol to dry before applying the tegaderm !