Documentation Between Visits...HELP!

  1. QUESTION 1: How do you as a visiting nurse document between visits. For example, you go to your clients home and setup meds, you phone the doctor about a concern or question, you leave. An hour or hours later, the doctor calls with your answer or a med change etc. How do you document this since you have left the home and have probably done your documentation for that client for the day.

    QUESTION 2: Your clients Primary calls and wants a medication increased or D/C'd. You are at the clients home and you need to set up meds. Do you set up the meds with the new verbal order and do a T.O. later for the doctor to sign or do you give the meds under the old orders until you get the new "written" orders from the doctor.

    What is your agency's policy on these two questions.

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    About athomemom56

    Joined: Dec '04; Posts: 103; Likes: 8


  3. by   Mr Ian
    1. Keep a diary and document as you go. Write the information on the page you are due to next visit (so you notice to do it that day) and date your entry next to the info as if a clinical file when you entered it. A personal diary is admissible in court as a working document.

    2. Check your local policies first - they may not even allow for verbal orders to be taken by one nurse.
    Nurses may clinically choose to give or to omit a medication. This is the extent of 'administration' for which nurses are responsible. They cannot choose to alter the dose (unless a written order states so).
    Advise the Primary of your position and that you cannot lawfully commit to those orders at that time or until such are documented. Set up the orders on the old regime or omit - and document in file and in your diary.
    You would then have to return to the patient to complete the new orders.
    (Alternatively - set up an email or txt message system as an interim written confirmation as your evidence). It's not your job to make the systems of practice - but it is your responsiblity to raise them with your employer - unless of course you are self employed.
  4. by   athomemom56
    Thanks for your reply. This is how the visits are done. I see clients Monday through Friday. I don't see any of my clients more than once a week. Lets use client Mary as an example. I see her every Friday. I go to her home and do her vitals, Review of systems, Med Setup etc. Her BP is elevated enough to warrant a call to the Primary, and you know who I get to talk to, the nurse of course. She tells me she will pass the info on to the Primary. Hours later at the end of my day, lets say it's around 5pm, the nurse calls me back and states the primary wants to d/c one of Mary's BP meds. I request a written order. Of course I am not at the office to receive the faxed order, plus its now the weekend. Now remember, Mary's meds are setup with those old BP meds for a week when I will see her next. So this would mean she would still take that med til I get the written orders which would probably be Monday. This is just one of many examples. Side Note: When I do my visits, I have a "Skilled Nurse Visit" sheet where I document everything I do that day and plans for next visit or any calls I made etc. BUT, there is no documentation of that order from the primary to stop the BP meds, that call comes later after I have documented for that day.
    I need to be able to document what the nurse called back and said, when I plan on making the change (when I receive that fax), etc. This goes on all the time. If a nurse or primary makes a mistake with a verbal order, WELL... that's why I need to document everything. Here's what I have for now. I have a "Mead" mini 3-ring binder. They are wonderful and fit in my purse. You can add ruled paper to it (they have paper refills to fit it). I have made my own divider sheets (just took the alphabetical dividers that are made for index cards and made a pattern). I have a section called "clients" and I have a sheet of paper for each client. I write all correspondence that relates to that client between my visits, whether it be communication between myself and the doctor, nurse, case manager, DON, or the client. I also have a bunch of tiny post-its and flags on the inside of the back of the binder. On the first page I jot down anything that needs immediate attention. I also have my calendar for the month (shrank down to fit the mini binder) and other info. When the clients personal page fills up, I take it out and add a new page, saving the old ones of course. I LOVE IT!!! ....BUT, will this hold up in court?
    This is really hard for me in that I don't see the client everyday, I get calls back from doctors, nurses, etc. all times of the day.
    ONE MORE THING: Now imagine having a case load of let's say 35 clients. You are out in the field all the time. You get new orders all the time, which means instead of following your scheduled appointments to do your visits, you would be running across town to the office top pick up new orders left and right, totally changing your schedule.
    Can't wait to hear some responses.
  5. by   Mr Ian
    Firstly, your (lawful) responsibility is to follow written medical orders. And I would not take a verbal order from a nurse at all. A doctor's verbal would only be half as bad.
    Your professional duty is not to run around and get those orders - but it is to do what is in the best interest of the patient.
    You have a legitimate issue to raise with the employers in regards getting the written order to you in a timely fashion.

    Your "Mead" sounds fine - but keep it for business use only (not sure how HIPAA covers you for such use - but should be ok if they are stored in compliance with any regulatory requirements). Don't include your personal info in there as then it becomes a 'personal' record as opposed to professional one. Strictly business.

    I'm making an educated guess on both of these - I would raise them both with your BON as a professional standards issue and seek their advice.
  6. by   caliotter3
    All agencies I have worked for have had a form called something like "Communication note" or "Case communication". It is a form that has a lot of blank lines on it and usually several check off boxes to indicate what discipline is doing the note and what discipline(s) the note is for and/or some indication of what the note is about. All things that occur outside of the realm of a visit (and sometimes things that happen during a visit) are documented on this form. I use several of these on a regular basis with these purposes: provide a more complete record for the client, inform my supervisors about what is going on, document things that I want there to be a record of. Your examples fall under my criteria above. For the example of the TO of a med change where you talked to the doctor. I would write up the TO and send it to the agency (or directly to the MD, depending on your agency policy) for signature and followup on the 485, keeping a suspense copy in the field chart. I would comply with the doctor's order at that point in time. You know the doctor is going to sign the order because you received the TO. The paper you send forward is verifying this in writing. You don't have to wait for the signed order to come back in order to implement it. I only hold back on implementing an order is there is some question and I'm waiting to see what the doctor's response is. I would fix the med box, do the patient teaching, and add, delete, or change the appropriate order to the med sheet. I would also insure there is a suspense copy of the TO in the chart with the 485. If need be, I would write a short note in the communication book to oncoming nurses to explain what has happened.
  7. by   athomemom56
    All agencies I have worked for have had a form called something like "Communication note" or "Case communication". It is a form that has a lot of blank lines on it and usually several check off boxes to indicate what discipline is doing the note and what discipline(s) the note is for and/or some indication of what the note is about.

    Yes, we use a form like this, its a skilled visit sheet. But I need a way to keep a record of things that aren't recorded on a visit sheet, for example when I get a call from the primary or nurse when I am at home....there might be many calls back and forth on the same subject for the same client. All of this information will not fit on that one sheet.

    If need be, I would write a short note in the communication book to oncoming nurses to explain what has happened.

    In my case, there is no oncoming nurses. I am pretty much the only one who sees my client except for the recertification.

    Thanks so much for your tips,
  8. by   athomemom56
    Does anyone know when I will be able to email a member privately. I have posted quite a bit.
  9. by   caliotter3
    With the number of posts you now have you can already PM members. Click on the members name in a post. On the pop up there will be an icon that I think has a pencil on it, that will bring you to the PM portion of the site. Or you can click on My Account and scroll down to Private messaging and follow the directions there.

    Your response to my post concerning the case communication sheet was a little confusing because you called it a skilled visit report. It sounds as if your agency has the nurses doing visit documentation on nothing but a sheet of blank lines. My agencies have some sort of check off type sheet that may or may not have the hours worked certification on them. We can use a blank lines type form to write an additional narrative to the skilled visit report if necessary. The form I am referring to is used strictly for info to be conveyed that is not included in the daily visit documentation. That is why it is used to document all that extra stuff.
  10. by   athomemom56
    I tried clicking on our name and nothing really happened???

    When I go on a visit, I have a form that has sections for each body system. It is a check off box for reviewing. At the bottom of this form is a lined area for documentation. It is then signed and dated and I turn this in every week. But I do not document on this form in between visits. This is what I was asking about...the in between time.
  11. by   UM Review RN
    Athomemom, you should be able to see the member's name that you want to message and near it is a little icon with a pencil. Click on that. The screen should come up for you to fill out your message and send it.
  12. by   athomemom56
    Yes, it works!!! Thanks.