Latest Comments by KountryPrincess

KountryPrincess 1,113 Views

Joined: Nov 13, '12; Posts: 25 (40% Liked) ; Likes: 15

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    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.

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    Mr_DEF and bbuerke like this.

    If I can add one thing to that wonderful post....you *will* get close to your patients, it is hard not to, and it is one of the benefits of being in Onc. Never forget that you are not thier friend, you are their *nurse*. You must be their advocate, a good ear for their problems, and an excellent medical professional. If the relationship changes into a friendship type relationship, you are robbing them of being able to interact with you as their nurse......ie they may spare you important info because they do not want to bother you or hurt your feelings. I have seen nursing staff get inappropriately close with their pts and it really disturbs the ability to give good care. Do not get me wrong.....I adored my patients, and you will always get more involved with some than others, but never forget that they need you in your professional role. It is ok to cry with a pt from time to time, but otherwise, let off steam about your feelings with you coworkers, friends and family. That will allow you to be the strong, confident, kind and above all, professional, nurse your pts need.

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    I got my OCN years ago when I worked in onc and the test was hard, but I did do really well on it, and I was proud to add it to my educational background. BTW, I have never belonged to ONS and still get all their newsletters etc. even though I haven't worked Onc for 10 years. I would not renew the membership if I were you , but I would get certified.

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    Great post Kel.....very informative.

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    I would move to med onc. That is the type of floor I started on as a student for a year and then as an RN for the next five years. I loved it, and you will probably find a great group of nurses up there. On my floor we were very supportive of each other emotionally, because med Onc can break your heart when you do get those close relationships with your pts. You will continue your education and get proficent in chemo administration and teaching. I would go for it, sounds like that is where you wanted to be in the first place.

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    Lol.....this topic reminds me of when I used to take call and sometimes got called out in the middle of the night and never knew exactly what I was heading into. I always took my 110lb Rottweiler with me in the car.....just in case

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    TrueAtHart likes this.

    With all your experience I am sure you would be an asset to any agency. My agency did not exactly throw me too the wolves, but when I started I was seeing some pts on my own within a week or so. However, they started with easier pts that I had already met shadowing
    the other nurses, and I still had to go to OASIS classes for the first month I worked there, and gradually, I would get checked off by the other nurses doing things like IV care, vp labs, foleys, ostomys, wd care, anticoagulation monitoring etc. After about 2 months I was pretty much on my own. I work for a rural agency with a huge driving radius. When I started, a full day was 5 patients or the equivilent (opens are considered 2 visits). After we went to computer doc. our productivity is expected to be 4 patients or the equivilent.....yep it went down because the doc. is soooo time consuming. I only work part time and I currently do mostly opens....it is my preference and my supervisor agrees it is my strong point. I love to meet the pts and be the first impression of the agency, come up with a plan for them and really start the teaching about meds, disease process etc. Then I turn them over to the CM......hopefully with the best start I can give both the pt and the CM with the pt. I love it. When I have to do revisits now I get cranky....lol

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    I would never work at a place that pays by the visit. When you have used your time, energy, wear and tear on your car, effort and expertise dealing with the pt, doc and family, amd the pt does not open for some reason, and you don't get paid, then it will be clear to you why many HH nurses will not work for "pay-by-the-visit" agencies.

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    PCH85 likes this.

    I agree with getting more hospital experience, I would aim for at least 2-3 years acute care experience. People who do homecare without that experience will tell you they do fine, but they do not know how they would perform differently if they had the experience, because they never got it. In short, you don't know what you don't know. As for the suggestions to do HH per diem to "try it out", that really doesn't work well in practice. The reason is, you need to work consistently and often to properly learn OASIS documentation. It depends on the agency of course, but per diems typically work sporadically and often on weekends. Our agency will not hire per diems without OASIS experience because they just do not work often enough to learn to do it well. They will hire case managers and part time staff without OASIS experience because they will be working often enough, and during regular business hours so they can get regular guidance from supervisors and QI on how to properly do it. At first glance, OASIS seems like a no brainer, but it actually takes a couple of years IME to be proficient at it. If you gather OASIS info incorrectly, your agencies outcomes will be screwed up. Learning to do OASIS honestly and accurately is the key to an agency making money. Medicare fraud is rampant in homecare, and nurses that can collect OASIS info correctly and accurately to reflect the good outcomes at an agency are worth their weight in gold. Additionally, there is always more to learn about it, changes in interpretation etc. occur at least monthly with the Moos....you have to keep up to stay good at your job. What shocked me about homecare when I first started was that *all* my charting was reviewed with a fine tooth comb....not just OASIS. A good agency will do that, because that is what the state, the feds, and JCAHO will do. Ultimately, if I were you I would stick it out in acute care for another year or so, and start doing reasearch on finding a really good HH agency to apply to. Then go for it, get a part or full time position and give it a shot. Trust me, you will be glad you paid your dues in the hospital and you will be more confident and really enjoy all that a good agency has to offer it's nurses, and you will be on a new learning journey.....the world of medicare and reimbursment.....it can be a bit daunting at first, but you can fully concentrate on it because your clinical skills will be finely tuned already. Good luck!

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    Not in California. Must be an RN.

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    Depends on the pt. If it is a pediatric pt with a pediport and an emaciated sunken contracted upper torso and the thing rolls, yeah.....you can miss. Really though, I would say in gerenal, on 99% of pts, portacath access is a snap compared to peripheral IV access. BTW I really admire you guys with good peripherial IV starting expertise. In my 15 year career I have never had to start an IV & it really intimidates me. I worked inpatient Onc for the first 5 years of my career where the pts had central lines mostly and if they didn't, we had an IV therapy team. Now in HH for the past 10 years, we don't do home IV therapy unless the pt has a central line.

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    davianrt66 likes this.

    I agree with the above poster....pay by the hour is waaay better. When you have spent 30 minutes round trip driving to a pts house, another 45 sorting them out and then do not get paid for any of it because they NTU(not taken up), you will not be happy when you do not get paid for your time and expertise. Pts can NTU for a variety of reasons....refuse care, not homebound, no skilled need, already on with another agency, unsafe home enviornment (for the HH staff). Many times you do not know that they are an NTU until you actually meet them and get to know their situation. My time is valuable, and I wanna be paid for it. It takes just as much clinical expertise to decide an appropriate plan for a pt that does not come on to service as one that does....if I make the wrong decision and do not open someone that really needed us and something bad happened, I would be at fault. HH is wear and tear on your car that is generally not reimbursed, though gas usually is. I have been doing HH for 10 years now at a great agency, but I am on my third car, and this time I decided to go with a lease. I worked out my average milage over the years and that is part of my contract with subaru. I only work part time. so my mileage is less than many folks who work in HH. My plan is to turn my car in after three years and lease another. I am sick of making car payments for years and then by the time they are payed off I am paying for constant repairs. This way I am constantly paying yes, but I always have a nice new car to drive, plus I have full warranty and maintenence included in my lease along with 24hr road side assist. Don't know why I brought up cars specifically,
    right now except that they really play a *huge* part of you life in homecare. You *must* have reliable transportation.....we go places where believe me, you do not wanna be stranded. Plus, you will spend at least 1/4 of your work day in your car, so it needs to be comfy on your back etc. I figure I spend that 1/4 of the day driving, 1/4 seeing pts, 1/4 documenting and the other 1/4 on the phone (arranging my day, calling docs, calling pts, giving report to the case managers). The uninterrupted one on one pt contact I love. Taking call can be a pain, but it can also be a great way to earn extra money. We make abou $100 a night baseline for being on call. If you get any phone calls and start interacting with patients, then the money starts to pile up. We get time and a half for any time spent dealing with pts including phone calls, documemtation, driving to the home and of course the visit if one is warranted. We bill for that in 15 minute increments and even if you just get a couple of "I need advice" type phone calls and then document on them you can make several hundred in just that night without ever leaving your house.

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    How about home care? Think about it a little and see if it might be for you. A little more acute care experience would be preferable, but I am seeing that new grads are getting jobs in some agencies, and you are more experienced than that. I have chronic back pain too from a disc out at T6, and although it is not easy, I am able to work in home care three days a week. The reason it works for me is that it allows me to change position frequently......drive for a while, stand for a while, sit down for a while in the pts home, etc. Also at my agency, if I am really hurting I will go home after I have seen my pts and chart lying down. You will find something, keep your chin up!

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    This does not sound like an ethical agency. I have been in HH for 10+ years with the same agency, and my responses would *never* be changed by anyone, not even my director, without my consent. I am called upon occasionally to defend Oasis answers, but that is normal. This agency is practicing medicare fraud IMO. Turn them in and get out! Also, I agree with the poster that had issue with LVNs being the primary ones seeing the patients. This agency is out to save some money big time! Our agency does not even employ LVNs, that is unheard of to me. To ask RNs to just doc on OASIS stuff and risk their liscense by never otherwise seeing the patient is crazy!!!!

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    Hi guys.....I am glad to see the interest in home care, but as someone mentioned, I feel that you need 2-3 years of acute experience, preferably more, before coming to home care. I noticed that the above poster has paramedic/emergency type experience.....congrats, that is not a field I have experience in, I am sure you will be a fab nurse.....however....it is not "dire" situations where inexperience shows. Those are the easiest things to deal with in home care....call EMS. It is the day to day managment of patients, watching their response to meds and treatments, and making good clinical decisions where inexperience really shows. In a hospital, you have the benefit of learning from other nurses, docs, resp therapists, etc......you also have the ability to be exposed to numerous pt situations that will allow you to develop your "sixth nursing sense". That is the sense you need when your pt appears fine....all vs wnl, no apparent problem. An experienced RN can detect things.....the sublte shade of color, a smell, an expression....something you cannot put your finger on and you cannot teach, but something that tells you something is amiss....and then, an experienced nurse will have a suspicion of what it is and how to deal with it. The thing is guys, you don't know what you don't know. In homecare, as you may have discovered, certian sitiations come up once in a blue moon. In the hospital, you would have regular exposure to those situations.....daily, whereas in home care you might see them once or twice a year. The only way to quickly become a jack of all trades is that hospital experience. I understand people are desperate for jobs and that may be how some new grads are ending up in home health, but I encourage you to keep looking at the hospital, maybe a per deim position in acute care to compliment what you are learning in the home setting? I think you will be surprised at what you learn. I did inpatient oncology for five years, but have spent the past ten in homecare, so I do know a bit about it. My agency has never hired new grads, and they rarely even hire an RN without homecare experience, so you guys are lucky to have found jobs. Good luck to all of you, and welcome to home care!


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