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Need help with notes

Posted

Has 7 years experience.

Ok i started home health and am having a lot of trouble with the documentation part writing the SN notes...is there a book i can pick up that can help me out with pt teaching , meds basic stuff that goes on the notes ?

The quickest way to get examples of hh notes is to read the field chart copies of what the other nurses have been charting. You will quickly see who is thorough and writes good notes. Emulate those and you won't go wrong.

KateRN1

Specializes in COS-C, Risk Management. Has 20 years experience.

Great advice, if you're able to view those notes. Our system is computerized and we cannot see other nurses' narrative notes--a sucky aspect of the system I think. Ask your supervisor for examples of good charting. Here's an example of the kind of things I routinely write:

Pt up in home, no acute distress observed. Alert and oriented x4, denies c/o pain at this time. Heart rate and rhythm regular, lungs clear to auscultation. Abdomen soft, non-tender, with + bowel sounds x 4 quads. Pedal pulses palpable, no edema. Pt saw PCP 1/15, new rx for metoprolol. Action and side effects of beta blockers explained, pt verbalizes understanding. Pt continues to weigh self daily as previously instructed, no weight gain noted this visit. Pt verbalizes understanding to call HH nurse or PCP for weight gain >3# overnight or 5# in one week. Pt states he fell early am 1/16, fall unwitnessed by family. Pt was in kitchen and fell backwards, denies increased dizziness at time of fall. Physician notified of fall via fax.

Good advice above. If you are using a flowsheet for your assessment, I would include the following in your narrative:

- ptś activity on arrival (even if itś resting comfortably in recliner) and any assistance needed to do what theyŕe doing

- other people in the home and their relationship to pt. remember when you are there you are fending for yourself. If there is ever a question about what took place during your visit, your documentation is your only defense. It can be good to know who was there & who was not.

- Any tasks performed, in great detail & echoing the plan of care (wound care etc)

- Any instructions provided & to whom, & their understanding (or lack of it)

- Be sure to indicate skilled need every single visit. I usually said something like ¨SN services continue to be required for skilled assessment & skilled instruction related to CHF (or whatever), and/or whatever skilled task you are providing.

Edited by HmarieD

thanks for the replies and the question. PT new to homecare here; a lot to learn!

thanks for the replies and the question. PT new to homecare here; a lot to learn!

Welcome!

When I audit PT notes (not looking for appropriate tx necessarily as I am not a PT, but looking for quality/compliance issues), I look to make sure that each clinical note stands alone in terms of exactly what tx, exs, gait training, etc were done. You can't say "exercises per plan of care", you must be specific on each note. Also remember to doc pt progress toward goals or lack thereof, and homebound status. I also check to make sure supervisory visits were done as per my state's regs if a PTA is seeing the pt. I also look for basic assessments like BP, SaO2 if done, pain assessment, and report to RN or case manager as appropriate.

I may get flamed for this since this is a nursing site, but it has been my personal experience that therapist's documentation is much better than the nurses. To be fair, there's a lot less of it, but what you guys do, you usually do well.