Home health charting ?

TheCommuter, BSN, RN · Jan 3, 2016

Hi!
Im a relatively new LVN. I just began a new case. I work 7p-7a. My patient is a child and the
parents care for him during the day. Sometimes they have done some meds and have started his last feelings before I arrive. My question is when I am here and they do his meds or feeding, should I at least sign off in his chart? I don't sign for what was done before I came in, I know that. Thanks

Thread has been moved to our Private Duty Nursing forum.

JustBeachyNurse, LPN · Jan 3, 2016

You circle your initials and describe in narrative if you witness parents administer and med or treatment. If you don't witness you leave it blank, and document "parent reports all 7pm meds given as scheduled before nurse arrival"

Cactus Nurse · Jan 4, 2016

Thanks for the tips. My first night I did write pm meds given by pcg as well as pcg suctioned (since I'm new they do things instead of me still ) kind of annoying but eh ok for now.

AdobeRN · Jan 4, 2016

We have a code we use on the MAR for meds given by the parent/guardian/other family member. I only chart it on the MAR if I see it given by the PCG - otherwise I will write in the narrative something like "PCG states all 7am meds given". I only sign my initials to the meds I have given.

JustBeachyNurse, LPN · Jan 5, 2016

Thanks for the tips. My first night I did write pm meds given by pcg as well as pcg suctioned (since I'm new they do things instead of me still ) kind of annoying but eh ok for now.

It's not uncommon especially in pediatric private duty. You don't know all the background and they are not comfortable with your skill and expertise having just met you. If you've witnessed some of what I have you'd understand (the newer grad assigned to precept a baby, first day home from hospital after 4 months inpatient in 3 different facilities. Tried to assess heart, lung and bowel sounds from 3ft away without touching the child. Wanted me to pull the NGT so she could see if she could safely replace it/practice on this infant (mother overheard horrified) had to send her home for safety reasons. Parent asked what to do as this nurse was assigned to work in two days. I gave her the clinical supervisor contact number to discuss her concerns. Unbeknownst to mom (it was a personnel matter not to be discussed with family) I refused to sign off the nurse's papers clearing her to work independently on the case. Same nurse was terminated three days later for showing up for a night shift with pillow & blanket because she "heard mom didn't mind" (mom did & sent her home, called out and called office texting a photo of sleeping nurse). Many parents are cautious when a new nurse starts.

SDALPN · Jan 5, 2016

You should be asking your supervisor. You can't verify that we are nurses. Also, agency policy will be your answer and policies vary by agency. Good luck.

Cactus Nurse · Jan 5, 2016

It's not uncommon especially in pediatric private duty. You don't know all the background and they are not comfortable with your skill and expertise having just met you. If you've witnessed some of what I have you'd understand (the newer grad assigned to precept a baby, first day home from hospital after 4 months inpatient in 3 different facilities. Tried to assess heart, lung and bowel sounds from 3ft away without touching the child. Wanted me to pull the NGT so she could see if she could safely replace it/practice on this infant (mother overheard horrified) had to send her home for safety reasons. Parent asked what to do as this nurse was assigned to work in two days. I gave her the clinical supervisor contact number to discuss her concerns. Unbeknownst to mom (it was a personnel matter not to be discussed with family) I refused to sign off the nurse's papers clearing her to work independently on the case. Same nurse was terminated three days later for showing up for a night shift with pillow & blanket because she "heard mom didn't mind" (mom did & sent her home, called out and called office texting a photo of sleeping nurse). Many parents are cautious when a new nurse starts.

omg! I am too terrified to sleep on the job! Wow. Plus my lil guys pulse of goes off when he gets to deep REM sleep and will hit 55heart rate then 7 seconds later he's bak to 72. So no time to shut my eyes. How horrible for the parent and that nurse to get fired for something so stupid.

Yea the parents are coming around to me little by little and I'm getting used to my pt a bit more

Cactus Nurse · Jan 5, 2016

You should be asking your supervisor. You can't verify that we are nurses. Also, agency policy will be your answer and policies vary by agency. Good luck.

The he agency told me before just write something like "pcg stated meds given" I just wanted to see if this is across all the boards like others do it also. Sometimes my agency is a little weird and they are too passive. Usually I'm not even writing because I'm not here anyways I'm just signing off and writing the ones I actually did.

Kitiger, RN · Mar 28, 2016

If the parents have given a med that is scheduled for my shift, I circle my initials in the MAR and explain in the notes. I state in my notes what time they gave any PRN that I might give. If it was "this morning" and I'm working nights, that's close enough. But if it was recent enough that I would not yet repeat it, then I state the actual time the parents state that it was given.

LeChien, BSN, RN · Mar 28, 2016

Every agency will be different. One agency I worked for had us write "P" because in the key it stated P=Parent, meaning the parent gave it.

Other companies I have worked for had us initial and circle.