Help!! How to document clinical info narrative - page 2

I'm an experienced RN but new to home health nursing; especially skilled nursing documentation requirement, OASIS, 60 day summary. I was hoping those of you with experience could be of assistance to... Read More

  1. by   nursebabyjan
    Kate could you send me a copy of the forms too? Thanks! Send to
  2. by   gayarn
    Kate,please send me a copy of the forms. Thank you!
  3. by   paradiseboundRN
    This book will help although it hasn't been updated to OASIS C yet.

    Handbook of Home Health Standards & Documentation Guidelines for Reimbursement

    T. M. Marrelli
    0 Reviews
    Mosby, May 22, 2001 - 680 pages

    A standard reference in the home health market, HANDBOOK OF HOME HEALTH STANDARDS & DOCUMENTATION: GUIDELINES FOR REIMBURSEMENT includes everything the home care nurse needs to effectively document care based on accepted professional standards. For each of the more than 60 clinical problems included, this handbook offers detailed standards and documentation guidelines including ICD-9-CM diagnostic codes, service skills, factors justifying homebound status, outcomes and goals, discharge plans, and specific tips for reimbursement.
  4. by   nurseklg
    Actually the OASIS C is in the book. Its out now! I just ordered mine from Barnes and Noble!
  5. by   ez2000
    hi kate, i hope you don't mind me ask/ng the same thing. can you share it to me as well? my email is at thanks a lot in advance! i owe you one.
  6. by   MsDorsey
    Hi Kate! I sent you a email. Hope you don't mind sharing with me as well. Thanks for being such a GREAT resource to the nurses here!!
  7. by   NRSKarenRN
    Admin Alert:

    Posting email address in threads allows spam bots to get hold of your account since allnurses is heavily indexed. Please use our Private Message system private_message_icon-png for requests.

    I've used Marrelli's Handbook of Home Health Standards & Documentation Guidelines for Reimbursement book since first edition published in late 80's. Newest 5th edition is also available on Kindle.
  8. by   Coastieskid

    Sep 19 by Coastieskid

    Hi Kate! Hope you don't mind sharing with me as well. Thank you in advance for helping out new healthcare nurses.
  9. by   annbabol
    Hi KateRN1 would you mind sending me a sample of narrative nursing note for home health care. Thank you so much.
  10. by   KountryPrincess
    Everyon at our agency charts narrative differently. Most nurses use Word templates, especially for revisits. We are required to use templates to document wounds and ostomies. Remember that your OASIS and other flow charting contains a lot of assessment info, so what I try to focus on in a narrative are my patient's specific issues that exist and exactly what teaching or actions I am doing to rectify the situation. I do a lot of Start of Care visits, and I was trying to use templates for various issues, but it is not working the greatest due to the wide variation in pt situations. What I have done now is handwrite a teaching guide for all different dx and what I want to make sure I cover with each of those dx. When I am looking over a SOC packet at my pts hx, I then start listing on a post it the dx for that particular pt that I want to address. During my visit, I go down my list and may flip back to my teaching guide to make sure I am covering everything. I make pertinant notes on the post it regarding that pt, specific issues etc. that I may address or need to fu on. Then when I sit down to write my narrative I just run down that post it, include the pts particular issues and what I did about them, reaction to teaching, and what we need to fu on at the next visit. Basically I use the post it as my brain trigger to get all pertinant info into the narrative. I have been doing home care for 10 years and our teaching and disease mgmt protocols are getting more and more detailed. I was finding I would spend ages with a pt, doing tons of discussion and teaching and then forget something silly like asking them if they had their flu shot. Grrr. so far this is working well, we shall see.
  11. by   Cyoung07
    Hello can i get the word doc as well..i am new to HH...also does anyone have a copy of SOC packet that they can email me..I am trying to get myself familiarize before i go out..
  12. by   trimarr
    Could you email me this as well. I am new to Oasis and home health and need help charting summary's . Thank you
  13. by   JustBeachyNurse
    Quote from trimarr
    Could you email me this as well. I am new to Oasis and home health and need help charting summary's . Thank you
    Don't hold your breath this is a three year old thread. KateRN1 has not bee on this site in 19 months since she was admitted to a CRNA program