HH drowning in documentation...help

[Terridts]

I've been a HH nurse for almost a year. I started as a new grad in my current position. I love my schedule, most of my patients, and my job. I need to find a way to be more efficient with charting. I work four 10's, but still come home and chart until 1 am. I owned a medical transcription company for 25 years prior to becoming a nurse so I feel like I should have this documentation piece down by now Any advice would be very much appreciated.

[caliotter3]

The best advice I was given about charting from an experienced follow-up visit nurse, was utilizing "boiler plate" charting. Of course if you are describing something that has changed from the previous visit you are going to have to describe the differences, but if this was a routine visit with the same presentation as the last one, you could write a note that closely follows the previous note, or write the boiler plate up to the point where you describe the changes, if you understand what I am trying to convey. This nurse also told me that her agency was ok with the use of "boiler plate", as long as the visit was satisfactorily done and the note met the minimum standards to show that the goal of the visit was met. In other words, she wrote a lot of the same stuff over and over because it applied over and over. Her agency was not looking for the next best seller novel.

[oceanblue52]

I don't know what your system is like, but I did almost all my charting in the home, unless I was running late or if it required a lengthy narrative. Do you use a laptop? A wireless mouse was super helpful in place of the track pad too.