Nurses notes

[Shimmer580]

Fellow nurses- I need help with my documentation!!

I've read so many forums in here about nurses notes and what to include but they are mostly about how you write a nurses note for the hospital. In home care- our notes are different.

I always feel like mine are so poor and when I read the other nurses notes, I feel like mine are pathetic.. ?

Home health nurses: how do you write your notes? I always start with how I found the client and end with how I left them and with whom ...

Our nurses note form is the body assessment is the top half and bottom half of the page is the nurses note section. Any tips or advice are greatly appreciated!

[nurseariana]

HH notes are used in conjunction with the 485. Section 21b has all the interventions you will be performing or covering. I pick one of the interventions listed and then explain what educated the pt on. Remember you must show a skilled need every time you go in.

[caliotter3]

Are you doing intermittent visits or extended care?

[Shimmer580]

I'm doing extended care. 8 hours shifts ... Usually day shift.

[caliotter3]

I can't right now but will try to send you a PM of an example when I get the chance. Might not be able to until Sunday. But I agree that you need to start with the 485. For example, if it says to flush the GT tube with 60 ml of water every six hours, then you need to chart that flush. If you work on day shift from 7 to 3, a six hour schedule would have you flushing the GT at noon, the night shift nurse should have flushed it at six am and the PM nurse will flush it at six PM. You have to address every intervention on the 485 to document that you did it during your shift. If it says to do PROM once each shift, that intervention should be charted as being done on your shift. One mistake lots of nurses make, is that they don't chart lots of these things (and usually don't do them either). Start by going over your 485 with a fine tooth comb and making a list of the things that need to be done on your shift, then use your list as a checkoff for your charting.

[Shimmer580]

Thanks! that's an awesome Suggestion. Even if it takes you until Sunday to send me a PM with examples, I will patiently wait and be sooooo grateful. Thanks in advance! :)