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Discussion

Point of Service documentation

My hospice agency is pushing hard for "point of service documentation" or charting in the home during nursing visits. They site several reasons for doing this including medicare requirements and, of course, the nurses have just as many, if not more, reasons not to. We are being told that many other agencies nationwide chart in the home and many use computers when doing so. We currently utilize 6.5 lb Dell laptops with Suncoast software. I am curious how other agencies are dealing with this requirement, patient's reactions, and clinicians acceptance.

Thanks

Featured Replies

Yes, our agency wants us to do this. And no, I refuse to. I think it violates the intimacy that is created between patient, family and me. I also happen to think it's rude...

JMHO!

mc3

I document in the home, on paper, just vital signs and such, last bm, number of voids in last 24, meds used in last 24, then I put the paper aside while we talk and educate. family signs bottom of my document, then I finish paperwork in the car. I too think it is rude to have face in paperwork while they are venting, or just talking.

linda

San Antonio, TX - I work for an agency and all documentation is done on forms provided by the company the patient is contracted with.

The company I work for utilizes this form of charting. The system is very user friendly, mostly checking boxes. I went from paper charting to computers and at first I thought the same that it would take away from the intimacy. I have found however that the pts nor the families seem to mind. Our laptops are notebooks so the screen flips down on itself and doesn't look much different than the clipboard I used to carry. It is nice too to have the complete chart in front of you. Makes recerts and case managing much easier. It does have some negatives though mostly technology problems. Batteries going dead, program running slow. And when a family is rushing me out the door (not very often) I just finish up in the car before moving on. It does take more time, so we don't see as many pts in a day.

We always complete our paperwork in the home and we leave a copy in the home. It is not difficult. most of it is checkboxes, and then there is an area for a narrative. I have not had any complaints about it. I explain to the pt at admission that we will complete the paperwork and leave a copy in the home in case something happens at night or on the weekend and a different nurse needs to come out, They will have access to the latest visit notes and VS. Sometimes when on call, the family calls about a problem and I will look through the notes and find out what has been going on. I can't imagine NOT having paperwork in the home, (unless we would get laptops).

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