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Nuring Documentation in the Home Health Setting

by nfarfan411 nfarfan411 (New) New

Good Evening,

I need some help or some examples on how to document for "Patient progress toward goals and response to instructions provided" in the home health care setting. Thanks


JustBeachyNurse, RN

Specializes in Complex pediatrics turned LTC/subacute geriatrics. Has 11 years experience.

What kind of goals? What kind of patient education/instruction? Usually response to education is verbalized understanding or return demonstration

Ask your supervisor to provide some examples. Some agency supervisors change their emphasis from one view to another and then back again within the span of less than four months, so it is best to get their take on what they want to see.

iluvivt, BSN, RN

Specializes in Infusion Nursing, Home Health Infusion. Has 32 years experience.

Just in general in response to instruction provided it could be a variety of things depending upon what was taught and what was the expected outcome or goal of the teaching. You need to assess the actual response to the teaching and document it as such.It may be something such as "patient and caregiver verbalized understanding of the teaching with a return demonstration completed successfully by the c/g". It may be the patient shows no interest to learning the necessary skills to provide the necessary self-care needed and/or prescribed. It may patient and caregiver verbalized understanding of all teaching provided but could not complete all steps of the return demonstration(s) so additional teaching visits will be needed.

The patient progress towards goals comments will also depend upon the goals of the prescribed therapies and treatments and nursing care provided. So if your patient's goal is to demonstrate safe adminisration of of the prescribed medication and your instruction allowed them to achieve complete independence in that self administration than that goal was successfully achieved!

Let's look at another goal.. The goals is that the patient and/or c/g will verbalize potential side effects and adverse reactions /complications of therapy that need to be reported to the RN/MD so appropriate action can be taken . Either the goal will be met or it will not..if is is not it needs to be addressed/reevaluated and maybe the goal needs to be revised.

Another typical goal would be determining what an acceptable pain level on the scale of 1-10. So if the patient states it is a "3" and you assess that the pts current pain regime is effective in keeping that pts pain at a "3", then you can say you have reached that goal successfully. If the pts pain is a "4" then you then state what nursing actions you will take based upon you assessment. Maybe you assessment is that they were not taking the Rx as prescribed (under dosing} and you reeducated them or perhaps you need to intervene and call the MD.

Thank You for your responses they have been quite helpful.....!!!!