New to home care and freaking out because of the documation

[PeacockMaiden]

I am a RN that is new to the home care venue. I got hired by a company that pays by the visit. I have spent 1/2 day in the field shadowing a nurse who was also fairly new so I really didn't learn anything. I had one day of training on the Oasis, revisit documentation, and doing orders. I am completely overwhelmed and they want me to start taking me own patients now.

The Oasis is on computer, and you can bring your own laptop or Ipad with you to see the client to do the documentation there if you want. The Oasis is 22 screens of assessment info, and if I sat with the client to do it all, I'd be there 3-4 hours.

Are there any paper cheat sheets that can be used to get all the pertinent info without having to go screen by screen with the client?

So far I'm very skeptical of this job. They don't offer mileage reimbursement, and couple that with the documentation taking hours, I don't think this will be worth the money.

I'd like to hear any hints anyone may have for better time management.

[BerkeleyBSN]

I'm relatively new to home health too, but I've found that the OASIS documentation gets easier the more you do it. It takes forever the first few times, but only takes about an hour after you get used to it.

I definitely would not advise trying to do your OASIS with the patient. Go to a coffee shop (and make sure no one can see your screen!) and fill it out right after you leave the patient so it's all fresh in your mind. I always make sure I can call the patient just in case I forgot to ask something.

My agency gave us a checklist but I'm sure there must be something online you can find, too. If not you can make your own. I just did a quick google search for "oasis start of care checklist" and it looks like there are things you can use.

I'm sorry it's so overwhelming at first, but you can do it. Just remember that OASIS gets much easier once you've done it a few times.

Best of luck to you!

And as for them not giving mileage, I thought that wasn't legal. Maybe it varies by state?

[Success2011]

Congrats on your new job..I am due to sit an interview for a home care job, what are some of the common questions asked and how do you think it's best to respond..thx..your feedback will be greatly appreciated..

[ChristinP]

I have been working in home care for about 5 years and with 3 different companies. Your orientation to homecare seems terrible. All of our nurses spend several weeks learning how to document a routine visit before moving on to Oasis admissions, recerts, and discharges/transfers. We all have our cheat sheets for documentation and most agencies have a template to use or you can make your own. It takes nothing but time to learn to how to complete an Oasis. Most agencies I know count and admission as 2 visits and recerts/discharges as 1.5 visits. Your company owes it to you to train you properly or medicare wont reimburse correctly. Good luck to you, I love homecare and wont leave at all.

[nyemt2005]

That doesn't sound like a great orientation. I just recently started at a certified home health agency, and we're doing at least 6 weeks of co-visits and documentation training before they begin to start letting us take on our own case load. I feel like I'll get comfortable with doing regular visits pretty quickly but the start of cares look very daunting.

[LaRN]

here are some links that should help you. ideally you should have a complete orientation, but this isn't unusual. you will learn, its just a bit more of a struggle.

on admits, just do a good assessment and concentrate on your medications and make sure the patient has all of them and is taking as prescribed and if not, do the best you can to begin teaching and of course notify md if any discrepancies. ask pt if they take any pain meds bc they dont always store them with their regular meds.

**don't stress yourself over the functional section of the oasis just answer the best as you can, and move on.

I usually make a cheat sheet for the data needed such as allergies, last md appt , flu and pneumonia shot, any equipment in home and supplier, get name and contact info for next of kin, who lives in home with patient (and primary caregiver), does pt have a living will or dnr, any supplies pt may need, if catheter, get size and last changed, do a very good skin assessment especially on those who have dementia, psychosis,etc. bc they're likely to not be aware of or able to tell you something is wrong, (measure all wounds and locations, &treatments if any ordered). list past major surgeries (i always look at the stomach to check for any ostomies), check chest for scars /cardiac surgeries, and *PACEMAKERS (note last time it was checked and ask if they have defilbrilator-). Ask if they take any "shots" and who gives them, list any significant md's they may see in addition to primary md. ask if pt is receiving any other services such as a home waiver program, any outpatient programs like adult day care. explain to pt and family if they will be getting any therapy it will have to be provided by home health. (unless something else has been worked out with Home health). if patients use a mediplanner, check with your agency for policy, bc some agencies discourage hh nurse prefilling them. its a lot of info to try to pull out of people, and before i begin asking the questions, i explain to the patient that I have several questions and I need them to briefly answer each one and move on to the next one, and if there are any areas that need more attention , i will go back to them after we are done. I do this because some patients have a story to tell with each answer and when i have to cut them off, they will know why and it wont seem like im just being rude.

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