Charting

Specialties Home Health

Published

I am hoping to get some input from seasoned HH nurses on how to tame the beast that is charting. I am super new to HH and for the past few weeks I have been taking notes during each pt visit and then charting when I get home. Problem is that I am losing my life to this ... I never get the downtime that we all need as my whole life feels like field work and charting. I love this job, but I knot that it is not sustainable at this rate and that I will become burnt out.

I have been told to chart in the home, but I find the iPad to be so time consuming. I hate charting at home, but without a doubt I am much faster using a traditional computer. I gave in home charting a try today and was able to get mostly everything in except narrative. I don't feel like it really saved me much time, but I am going to continue with this for now and see if it doesn't improve. Any advice on charting in the home versus charting later?

It's all about building a habit.

At the beginning while you're still learning, park after each visit somewhere comfortable but easy in easy out. Push your seat back and focus on your charting immediately after each visit.

Stick with this routine and you will start to feel more comfortable charting first in the driveway (so no time lost finding a place to park) and then the majority in the home.

If you chart in the home or the driveway, let your patient/caregiver know that you're going to take a few minutes to document their assessment and not to worry that there is a problem. If you're in the home they're likely to make sure that you are comfortable, if you're in the driveway they know not to come out and ask if there's anything wrong.

Patients/caregivers can be very accommodating when they 1) received undivided attention for 20-30 min 2) understand what you're doing.

Specializes in Pediatrics Retired.

You can chart in the home if you can do it without ignoring the patient while you peck away on the keyboard, aren't constantly interrupted by the patient or other distractions in the home, if you can stand to remain in the home because of the stench or heat or don't feel like you're about to fall through the floor, or if you can actually find a place that you can, or will, sit down while in the home. I've done HH and hated it and charted away from the home. My wife is a HH PT for 20 years and loves it. She has tried on multiple occasions charting in the home and it doesn't work for her. Like you mentioned, generally, it's going to take the same amount of time wherever you're "sitting" so she likes to come on home after seeing her patients, get into some comfortable clothes/jammies, turn on the soap opera or Judge Judy she has recorded and complete the charting then with no interruptions. Many times she is done by the time the kids and I all get home and she is free for the evening.

Do you have a keyboard for your iPad? I've learned to chart VERY little in the home, just enough to jog my memory for when I get home to complete the note.

Uninterrupted, comfortable documentation is so much easier, more focused and faster. When I worked in LTC I had many skilled narrative notes to do. Once I gave report and counted off, I had a half and hour to do uninterrupted charting. I got more done in that 1/2 hour than I did all day. Many clients are lonely and want your attention and want to talk, God bless them, they deserve as much of your focus as you can give :-)

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