Charting in the home

  1. Is it a jhaco (sp?) Standard to get as much charting in the home done?
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    About jennispen

    Joined: Jan '14; Posts: 5; Likes: 4

    5 Comments

  3. by   Libby1987
    No but documenting at point of service is an industry standard for accuracy and efficiency.

    It's still a hard fought battle as it is common practice to put it off until the end of the day. Home Health has a reputation for having to chart into the night, yet clinicians have a hard time building the habit. A lot of reasons are given but it comes down to habit and routine.

    JCAHO

    https://www.jointcommission.org/stan...False&Keyword=
  4. by   sunnysideRN
    Hi Libby1987,
    I'm newish to HH and I've finally begun charting my follow-up visits in the home. It's amazing what a time saver that is at the end of the day. I'm wondering how feasible it is to chart a SOC/ROC/Recert/DC in the home. Any tips for making those lengthier assessments more manageable? I've received a lot of valuable tips and tricks from your replies to various posts!
  5. by   Libby1987
    Glad to hear it's helping!

    For charting SOCs etc, it depends on the patient/home situation. For those who would enjoy your quiet company and allow you to concentrate, it can be mutually beneficial. I've sat many times in the home completing SOC documentation while the caregiver runs to the store. For those who are distracted/exerted by the visit or the home setting isn't conducive, it's better to chart at an alternate secure site on the way but before going to next visit.
  6. by   sunnysideRN
    The prospect of coming home at the end of the day with nothing or very little to chart makes me giddy

    When I'm scheduling patients I've started to allot some time for charting. For example for a follow up I'll allot 30min for the visit and 10 min to finish up charting in my car before moving on.

    For SOCs I usually spend 1hour in the home doing my assessment, med rec and collecting data for Oasis(I have a cheat sheet). It then takes me about an hour to complete the Oasis plus a comm note for the schedulers. So would you block out two hours before scheduling your next patient so that the bulk is done in the home or somewhere nearby (depending on the pt/environment)?

    Over time, do you think my SOCs will get faster or is 2hours reasonable? If you have any tips at all about streamlining SOC's I'm all ears
  7. by   Libby1987
    Quote from sunnysideRN
    The prospect of coming home at the end of the day with nothing or very little to chart makes me giddy

    When I'm scheduling patients I've started to allot some time for charting. For example for a follow up I'll allot 30min for the visit and 10 min to finish up charting in my car before moving on.

    For SOCs I usually spend 1hour in the home doing my assessment, med rec and collecting data for Oasis(I have a cheat sheet). It then takes me about an hour to complete the Oasis plus a comm note for the schedulers. So would you block out two hours before scheduling your next patient so that the bulk is done in the home or somewhere nearby (depending on the pt/environment)?

    Over time, do you think my SOCs will get faster or is 2hours reasonable? If you have any tips at all about streamlining SOC's I'm all ears
    Anything faster than 2 hrs for a SOC visit, documentation and follow up is not thorough. I can be very quick but even a straightforward TKR will take min 45 in the home. Anything with medical, treatment, psychosocial, disorganized meds and/or multiple teaching to manage should take 1.5 hrs if you're thorough and not missing needs that can or should be addressed at SOC. I believe strongly and in my practice I did things on the front end. 2 thorough back to back visits at SOC and you've established a strong foundation that you or other nurses can easily follow and care stays on track.

    I've known many nurses new to HH that make 1 hr or less SOC visits and they didn't realize what they were missing. I don't mean within the basic requirements of the admission visit but the extra needs and risks with the patient and their situation that an experienced/motivated nurse will pick up on and address either at the visit or within their care plan.

    That sounds pretty preachy but not intended to.

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