home health documentation

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I am new to home health nursing and do not quite knowwhat to put in the reason for visit form. I have so far put "SN to assess and evaluate patients health status" I belive that this is to vague. DOes anyone have any comments as to what else I should include to make the documentation better? An example would be wonderful!

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Did you do any teaching, wound care, set up of meds, checking of meds, safety check of the premises, provide referral information, etc.? Anything that you did could be put there but I would be inclined to stick with the generic statement you are using and just check off any of the other services where ever they appear on the sheet.

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ty that is very helpful

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Yes, I think if you get too detailed and repetitious in the space for reason for visit, that you would probably be making the note more work than is necessary. If you do a specific task and it is covered somewhere else on the visit sheet, there really is no need to duplicate mention of that in the reason space. Just continue to write what you have been writing. Your supervisor will be sure to give you feedback if this simple statement is insufficient.

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Thank you very much. It is nice to get feedback.

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Here's a question for you caliotter3. Electronic Documentation Theft.

Another nurse copied and pasted my clinical notes to her own notes on the same patients we were seeing. I reported it to my nurse manager. I consulted my board of nursing. The nurse got a write up as far as I know, which hardly seems adequate punishment for her deed. My question to you is: Do I have any legal grounds to sue this nurse for theft of my documents and if so what type of attorney would handle this sort of thing? I am not going to state my intentions for this employer in this forum. You never know who is reading these posts. I will say that I am not done with this yet. I have what it takes to see this through, and of course I have truth on my side. I am hoping Lamazeteacher will pick up on this post as well. You two present as well versed in the Home Care arena. Thanks!

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I personally don't see the point in pursuing this. But anything dealing with nursing might be better handled by an attorney familiar with the nursing profession so I would have to advise you to have a consultation with a nurse attorney. You can find them at the referral service of The American Association of Nurse Attorneys, http://www.taana.org. However, I still think you would be going overboard and putting yourself at risk with the employer. They will get a bad attitude toward you if you try to take this out of their hands. JMHO

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That's why I asked your opinion, much appreciated. My opinion is that a bum has a better moral compass than this nurse. The bum is just out there begging for change, not stealing it. I

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That's why I asked your opinion, much appreciated. My opinion is that a bum has a better moral compass than this nurse. The bum is just out there begging for change, not stealing it. I

Well, all I can say is good luck to you. I hope that it is not you that gets destroyed in the process.

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