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Discussion

Nursing notes, need help quick with times

I have been a home health nurse for a few years and love it. I have the same patient for at least 8 hours a day. When I started charting I did it q two hours but then I went to summary notes. Now we are back to at least every two hours. What times do I write the notes? Do I write it using the time I start or did it or am writing it. I pile a bunch of stuff into one block so I woud have a million times if I broke it down. Ill paste a copy too bc it may be all wrong. My boss who is the owner of the company is not a nurse and has no clue what she is doing. I type my notes and am trying to make sure the one I wrote Friday is ok bc she said Medicaid came in and checked my chart and asked to see the last week. I am really hoping she is doing this BC it is time for a new Medicaid care plan. i wont be able to post times but each paragraph is a time and the times are like 1100 which is when i get there and then 1220 and 1300 and meds are at 1400. Any help is greatly appreciated. Thank you so much.

This is actually 1100 t0 1900 and those are my shift hours. It just doesnt seem right. Do 'i set apart each thing done with time? im soooo used to summary reports. Thank you so much.

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    • Experts

    Welcome to AN!

    thread moved for best response

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    • Experts

    First entry is the time you started, if you were 20 minutes late, will reflect that. From then on, I would chart "general" stuff every two hours. Specifics, like PRN med admin or your assessment in response to condition changes, get their own time. I would not chart using the time you are writing the entry (if substantially different) because that is no different than a summary note. FWIW, I charted using times for the previous client, but with current client, only a summary note, because of the nature of the care.

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    As above.

    Chart actual tasks and medical interventions as the time that they were actually accomplished.

    If you must document on a time table (ie; Q2h or Q4hr, etc) then those notes are a summary of the events and observations of the previous hours. If you have a care plan, chart according to the care plan, reference it in your notes.

    Does that make sense?

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    • Author

    It does make sense. It is medicaid so it is every two hours but I guess I can put pt in crib with eyes closed etc for those. I also have a skilled care sheet which has peg care, trach care etc so can I just leave those out now? My boss changes things around if she gets an idea from someone who works at the car wash it seems so i never know whats right. i know to chart vitals on both or at least i have always done. She sent a text yesterday that said to only reflect fresh entries and not to duplicate any past entry so she must mean daily but my meds are the same asmostly tube feeds through pump. UGH. Thank you so much for any of your feedback and what all you have given me. yall are the best.

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    This actually sounds more like Private Duty Nursing than Home Health Nursing.

    My agency requires that we chart "something" at least hourly, so I make sure I have an entry at least every hour. Some of my notes are more detailed than others, and they reflect care that was given over the course of a period of time starting at the time I charted.

    For example, I might chart:

    2100 - Oral care and trach care including changing inner cannula and dressing, bed bath, change wet diaper.

    Obviously, I didn't complete ALL of those tasks exactly at 2100, but there is no clinical reason to chart:

    2100 - oral care

    2105 - trach care including changing inner cannula and dressing

    2115 - bed bath

    2130 - change wet diaper

    When making a charting entry for a period of time when I didn't actually "do" anything, I still chart that I assessed the patient's condition:

    0100 - pt resting with eyes closed, trach mask (mist collar) in position, breathing regular and non-labored, diaper dry.

    Then if I later change a wet diaper, I put the specific time that I did it:

    0135 - changed wet diaper.

    After that, I may chart another "assessment only" note at 0200, or I may wait and do my next one at 0230 -- my agency doesn't care if it's right "on the hour" or not, as long as we're charting SOMEthing at least every hour.

    Think of it this way -- if there isn't something to chart every hour, why is the insurance company paying for the patient to have skilled nursing care?

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