Published Nov 5, 1999
I would like to know more about documenting medications in home health. I have ordered many books related to this issue but none seem to ever actually make here. The net is my only reliable source of information, when i can get on it. I have little experience in home health, most of my experience is Med/Surg.
How do you document medications taken by the patient himself. For instance lets say that the patient takes Lanoxin everyday. You as a home health nurse only go into the home 3 times a week for educational purposes and to monitor his CHF. HOw do you document that he took the lanoxin on the days that you werent there? DO most home health agencies have seperate medication records or is it combined in with the Nurses notes. Remember that i am use to hospital nursing where you dont chart any med you didn't see go down yourself.
I would be grateful for any advice you wise and seasoned home health nurses.
The only way to deffinitively determine whether or not your patient is being compliant with their Medication Regieme is to either do Pill counts, or personally fill their mediplanner each week and check it on each visit. I dont know what the requirements are in your state, but in the agencies I've worked for, we periodically check their medications to ensure that they are still on the same meds, and to get a general idea of whether or not they are compliant. We aren't required to actually document that they are taking each dose, however it is important that we document that they are being instructed on the dosages, indications, desired effects and side effects of each drug
I have another question for you. What about weighing bedridden patients in the home who are on tube feedings or just weighing bedridden patients at the time they are admitted to the service.
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