New to HH Nursing, I need help with charting

caliotter3 · Feb 15, 2009

You should be able to find a copy of the 485 and examples of previous charting in the field charts of the cases that you are working on. If there is no field chart in the home, there is a problem. You can also ask to see these in the office.

cookie102 · Feb 15, 2009

we don't have "field charts" , the only thing we will find in the patients homes is a copy of the med sheet

99.9% of agencies are on computer so when the admission nurse completes the oasis that is what generates the 485, you might try pulling a chart, looking at the oasis and 485 and you will see how it was "put together",,,thumb thru the nurses notes and you will see what is written, you will develop your own style of charting, as long as you are following policy. give yourself a good 6 months to get a goot understanding of HH,,,you will get there...best wishes

Wishinonastar, BSN · Feb 19, 2009

A lot of places have some standard orders that they use, but a good 485 is like artwork- crafted to the individual patient. There are books out there you can buy. Looking at examples helps. The main thing about orders is to remember that you need to show that you are using skilled nursing interventions - assess, instruct, teach, evaluate. Monitoring is not very skilled. Your focus is not just nursing care, it is to make the patient more independent.

So, you take the problems- for example a wound:

Assess wound for healing and signs/symptoms of infection.

Instruct patient and caregiver in wound care procedure.

Dressing change regime- describe ie.- (cleanse with NSS, apply silvadene, 4x4, kling, tape. To be done daily. Caregiver will do on days with no nursing visit).

Instruct patient and caregiver in signs and symptoms of infection to report.

Assess nutrition.

These are all interventions associated with a wound.

The plan of care is a process-

Problem Identification – why are we seeing the patient?

Intervention Plans- What are we going to do for the patient?

Goal Setting – What to we hope to achieve?

Your charting should reflect how you implemented the interventions. Your assessment, your teaching, the patient's response, interventions such as reporting findings, and your plan for continued visits or discharge should be documented, along with the patient's continued homebound status.

Every visit must stand alone. If there is no skill in even one visit they can deny payment, even though we get paid for the whole episode at once.

Home health takes a while to learn but it still beats most nursing jobs hands down!

magdi · Feb 20, 2009

Thank you very much. Do you know about any good book I should buy to guide me? :)

Wishinonastar, BSN · Feb 21, 2009

The Handbook of Home Health Standards: Quality, Documentation, and Reimbursement has a lot of information. There are lots of books out there and Home Healthcare Nurse is a HH journal that has lots of good articles. Look around on Amazon or just do a Google search. There is lots of stuff out there. Does your employer have any resources for you?

Most HH agencies have a particular format for documentation. Ours is a note that has all the assessment areas - lungs, pulses, etc. in check boxes then on the back it has areas for narratives. One place I worked at uses SOAPIE notes which was helpful. Your workplace should train you in how they like things. All I can tell you is to focus on your skilled interventions and meeting the overall goals of the plan of care. Also continue to document the homebound status.

magdi · Feb 21, 2009

Thank you so much. I already ordered the book. :)

heartlover07, RN · Feb 27, 2009

I have found that the 485 is where I really think about what I want to do for this patient. It gives me a "road map" to follow when planning my visits and which interventions/teaching I plan to perform in a logical sequence. In the beginning I would make a copy of my 485 (it takes a while for the "official" 485 to processed) and refer to it when I was going to do a visit. Good luck and stick with it!

magdi · Feb 27, 2009

thank you