Help!! How to document clinical info narrative

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I'm an experienced RN but new to home health nursing; especially skilled nursing documentation requirement, OASIS, 60 day summary. I was hoping those of you with experience could be of assistance to me.

I work for a new, small agency that is getting ready for its first initial state survey. The agency is owned by an RN but her home health experience is limited; therefore my orientation was somewhat challenging. But she is a good friend and I'm trying to help her out.

I've done extensive research on OASIS, read the user manual on CMS website, view an online course but I'm still confused about some parts of it. I'm having problems with the part where you have to write a narrative as I don't know what to write.

For example:

(1) Endocrine/hematology Disease Management Problems(explain)- what do I write

(2)Pain

How does the pain interfere/impact their functional/activity level(explain) what do I write

(3)Cardiopulmonary Disease Management Problems(explain)- what do I write

(4) Fall risk assessment

The patient is a high risk for fall but then the question ask: plan/comment

Do I document fall risk interventions or what do i write?

(5) Living arrangement/supportive assistance

If a patient lives alone, but has a paid caregiver who assists with household chores. Does that counts as a primary caregiver?

(6) what has to be included in a 60day summary of care? A sample would be greatly appreciated.

(7) Skilled nursing note- I was told it has to justify why home care is being provided and speak to the plan of care and contain certain phrases or words. If someone has a sample they want to share.

(8) Those of you that have been through the survey process, what should we expect?

Any assistance is greatly appreciated

Thanks,

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Your manager should have some good examples ready of what they are expecting you to write. Put this in a Word document that you can copy and paste into charts, then tailor to your specific needs.

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Specializes in COS-C, Risk Management.

Write to me off forum at KateRN1 at hotmail dot com and I will help you as much as I am able.

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KateRN1

I tried emailing you at the email address provided but email was undeliverable.

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Specializes in COS-C, Risk Management.

Try again. That's my email address. Plenty of others have used it without difficulty.

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KateRN1,

Got the documents

Thank you so much

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Hello Katern1 I'm also new to home health care and having difficulty finding verbiage to the same questions. Do u still have a copy of the Word doc? If so please forward to [email protected] I would greatly appreciate any help you can offer.

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Specializes in LTC.

Please also email it to me [email protected] thanks!

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Starting my first home health care job tomorrow! Any chance I could get on that bandwagon, KateRN1? I would love a copy of that document too. Thanks soooo much. I'm at [email protected]

Marie

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Hi KateRN1. Would you mind sending me a copy of that document as well? Our summaries are so lengthy and we really want to revise our form. Thanks so much!

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Kate RN1. I forgot to send you my email address: [email protected].

Thanks!

Angie

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Hey do you guys think you could help me out? I am a psych nurse worked in hospita 7yrs and now went home health. I have no idea what I am doing. Psych is new to this company and I am told "It is your baby". Please send help.

[email protected]

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