I work for a large corporation and they are forever changing what is "required" in our documentation. When I started several years ago, orders were written kind of vague such as wound care: "cleanse with saline, cover and wrap". Now it has to be written, "skilled nurse to perform wound care to left calf using clean technique by removing old dressing, cleanse wound with wound cleanser, pat dry using gauze, apply medihoney 2mm thick, cover with non adherent dressing covered with abd pad and secure with tape."
We can no longer write "may accept orders from consulting providers" now we have to write may accept orders from Dr. Larry Smith, Dr. Michael Gray, and Dr. Susan English.
We have to write out a lengthy description of how the patient is homebound: limited range of motion of left knee, pain 7/10 with ambulation, risk of infection due to surgical wound, is only able to ambulate 10 feet and then must rest for 3-5 minutes due to SHOB before ambulating any more.
Diabetic foot checks must be documented on every single visit. Blood sugars must be documented on every single visit or we must document every single visit that the doctor has advised the patient that they do not need to check their FSBS.
Every intervention must have a goal date.
Cannot check a pulse ox without an order to do so.
Cannot write an aide care plan that has ANYTHING PRN because the aide is not skilled enough to decide. Cannot write that the patient may have a shower or a tub bath b/c the aide is not skilled enough to decide. (hello, can the PATIENT not decide?)
Do this and more in less time, less time, less time and don't you dare forget anything.