HomeHealth- skilled nursing visit note-follow up visit -lvn

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Hello guys,

I need help in writing "assessment/instruction/intervention" box part of the skilled nursing visit notes. My brain is do not function very well like I blsnked out and does not have any idea what to write.

For exapmple: I am supposed to discharged a patient so i took vital signs and assess. So i discharged the patient.

What do I write in thr box "assessment/instruction/intervention" or discharged teaching?

Please help. I am not very good at documentation. I just don't like visiting. I am more of like office/case management kind of person

Isabelle49

849 Posts

Specializes in Home Health.

As far as I know LVN/LPN cannot do discharge visits. What kind of agency do you work for?

JustBeachyNurse, RN

1 Article; 13,952 Posts

Specializes in Complex pediatrics turned LTC/subacute geriatrics. Has 13 years experience.

Discharge and assessment are usually out of scope of LPN/LVN and its limited to RN only. Teaching plans can be enforced by LPN but initiated by RNs.

What is your agency policy? We can't tell you what to write as we didn't see the patient b

JustBeachyNurse, RN

1 Article; 13,952 Posts

Specializes in Complex pediatrics turned LTC/subacute geriatrics. Has 13 years experience.

Why are you doing skilled visits as someone who received their license 3 months ago. Clearly you need more supervised practice. In CA you must have 1-2 years nursing experience to work in skilled home health. You need to contact your clinical supervisor for assistance.

Discharge and assessment are usually out of scope of LPN/LVN and its limited to RN only. Teaching plans can be enforced by LPN but initiated by RNs.

What is your agency policy? We can't tell you what to write as we didn't see the patient b

While I agree that LPNs should not be discharging patients, my agency allows it for private pay and private insurance (eg non-medicare/aid) patients. Of course, they also allow LPN-only visits for weeks and weeks for frail pts who also have wounds. We sadly don't all work for agencies that do things the "right" way. Thank goodness for AN, where can learn and incorporate the right way into our personal practice.

That said, the OP stated he/she was supposed to discharge so took vitals assessed and dc'd. Does the OP even know if the patient was truly ready for discharge?

justjosy

23 Posts

My agency is weird. All of their lvns does dc because it depends on the patient dx and insurance thats how agency does and i agree iv never heard lvn does dc i had no choice i didnt kmow what to do i didnt if i should have not taken it

justjosy

23 Posts

Well i knew that DC is not in lvns scope. I knew that. My agency is really weird they said that it was ok for lvns to dc and they made sure and it depends with the patien dx and insurance and since pt is non medicare they made their lvns do dc. I didnt know what to do when they give it to me and idk why i said yes

JustBeachyNurse, RN

1 Article; 13,952 Posts

Specializes in Complex pediatrics turned LTC/subacute geriatrics. Has 13 years experience.
My agency is weird. All of their lvns does dc because it depends on the patient dx and insurance thats how agency does and i agree iv never heard lvn does dc i had no choice i didnt kmow what to do i didnt if i should have not taken it

Then you say NO I'm not available especially if you have no idea how to discharge. Now your license is on the line because you did the discharge and signed the paperwork. Hope the insurance company or CHAP doesn't decide to audit?

Then you say NO I'm not available especially if you have no idea how to discharge. Now your license is on the line because you did the discharge and signed the paperwork. Hope the insurance company or CHAP doesn't decide to audit?

It may not be as simple as saying "I am not available", especially at an agency that is not pay per visit. I have had situations where I have been asked to do procedures I am unfamiliar with and/or not seen since nursing school (well over a decade ago) and expressed hesitation with doing these things/requested training. In the beginning, this did not go over well and it was reflected in an eval. Now, I simply don't get asked to see pts like that, which is limiting my growth/expansion of knowledge and skills.

That said, there are things done in our office I know to be incorrect and I won't do them. I did have a few times very early on where I was instructed to do incorrect things (primarily paperwork related) and did not know they were incorrect. Now, if I am on the fence about whether I should be doing something a particular way, I research it or text a friend that works elsewhere. It can be exceedingly difficult to stand up for yourself like that, and for OP, it might be easier to find a different job. In my case, I am slowly getting some staff to rethink how they do things, including what we are asking LPNs to do. I am very firm about how I utilize LPNs for my personal case load.

justjosy

23 Posts

Before I went. I kept asking them if it was ok and i couldnt say no i kept asking if they were sure and so i thought they lvns dc so they have done this before.

Before I went. I kept asking them if it was ok and i couldnt say no i kept asking if they were sure and so i thought they lvns dc so they have done this before.

Getting back to your original question, as others have stated, you should really sit down with someone in your office and ask them to walk you through how to chart on this. Reading through charting on other, similar patients would also help.

I find that the role distinction between LPN and RN can be challenging, if there are no policies laid out at the agency. Is there anything in writing at that agency that spells out the LPN role? I have friends who work at a different agency and they have a very clear understanding of what LPNs can do, how often, etc. They have written policies and it makes it much, much easier. When I am in doubt, I refer to what the other agency does.

JustBeachyNurse, RN

1 Article; 13,952 Posts

Specializes in Complex pediatrics turned LTC/subacute geriatrics. Has 13 years experience.
;8854037]Getting back to your original question, as others have stated, you should really sit down with someone in your office and ask them to walk you through how to chart on this. Reading through charting on other, similar patients would also help.

I find that the role distinction between LPN and RN can be challenging, if there are no policies laid out at the agency. Is there anything in writing at that agency that spells out the LPN role? I have friends who work at a different agency and they have a very clear understanding of what LPNs can do, how often, etc. They have written policies and it makes it much, much easier. When I am in doubt, I refer to what the other agency does.

I think part of the problem is per post history this is a new grad LPN that is in over her head doing skilled visits. Clearly she didn't get extensive orientation & training that a new grad needs and deserves. She was sent to do a discharge that she clearly was not taught how to do the assessment, patient education & documentation for a patient discharge.

The agency is taking advantage of an inexperienced new grad.