andre

Our agency is on an EMR so it's really only consents, port DNRs/copies of advance directives and pharmacy auths to turn in. The expectation is to turn everything in within 24 hours of the admit. Or 24 hours of the revocation/discharge. And ok to fax and then turn the originals in next time you're in the office.

arggggggggggggggggggggggggggggggggggggh.:banghead::banghead::banghead::banghead: I can't possibly be the only one trying to figure out how we're supposed to have any time left to see patients with all the new documentation requirements??????

What we have done in these scenarios is explain to the pt and family that if they call 911 or go to ER without calling us first, they are revoking their hospice benefit as that is outside our plan of care. There are occasions where we will ok hospitalization if the diagnosis is treatable and clearly outside of their hospice diagnosis (such as a recent patient with new onset seizures.....hospice diagnosis is cardiac). I think rather than making a blanket decision to discharge the patient in 30 days, now is the time to once again educate the pt and family about hospice philosophy, reevaluate patient goals, and establish a plan of care where it is clearly documented that all are understanding that 911 calls/ER visits without first discussing with hospice team means you are choosing to revoke the hospice benefit. Hope that helps, Andrea

I had this same experience when I had the flu a few years back....missed two consecutive days of work and was required to get a doctor's note. I went to my MD's office but saw a covering MD who, when I told her why I was there shook her head and said, "Wow, what are you, three? I can't believe they're making you do this....I'll be right back". She did no physical exam, just left the room, wrote my note, came back in and said "Feel better....go home and go to bed." Her note said: "Andrea has the flu. She may return to work tomorrow if she is feeling well enough, otherwise she may return at her discretion. Thank you for wasting an office visit by making her come in." :chuckle:chuckle:chuckle:chuckle:chuckle:chuckle It just makes me burn....I agree with you completely. We take care of incredibly sick patients--why is it so difficult to see that we do, in fact, know when we just have the sniffles and are capable of safe care versus when it is unwise, unsafe and generally a lousy idea for us to come to work? Andrea

Ok. I totally understand that nursing is a 24/7/365 operation. Really. And I knew when I went to nursing school that I'd be working weekends and holidays, and planning my vacations six month in advance, at least while I worked in the hospital setting. But seriously, why bother even giving people the opportunity to earn sick time if you are going to punish them for using it? I myself, though never warned or terminated for it, was routinely "dinged" on my annual evals for "excessive absenteeism".....though I only took sick time I had earned. Every year I had the same response for my manager: "I understand your policy, but I disagree with it. If I am sick or I have a sick child, and I have sick time to take, I am going to take it. I call in well in advance of the shift so I don't leave anyone in a bind. I have also been known to come in when asked on my day off because of other staff sick calls, or to help cover vacations. I disagree that it's excessive absenteeism if it's within the limits of the time I earn." And every year we'd agree to disagree, and I'd go back to the floor.... Now I work in hospice. I work very few weekends, I have paid holidays, and if I call out sick I am told "Feel better....take care of yourself." In fact, the few times I have gone to work sick because of the expectations I had absorbed that that's just what you do as a nurse...and I was told "Go home! You're sick! We don't want you seeing patients like that!". It just makes me so angry that so many of us are made to feel like criminals or bad employees for taking more than 2 or 3 sick days per year! Sometimes life just doesn't work that way! And no one should be made to feel bad about that! Ok, rant over. Andrea

I'm not case managing any longer, but when I did I carried a caseload of 12 and generally did 4 visits and several phone calls per day. Five visits was BUSY and happened sometimes, but I never did more than that.

Our agency is now on Road Notes, which is fine but is not terribly intuitive. I hear GREAT things about HealthWyse (have a friend who is a project manager for that company). I've heard very mixed reviews about McKesson, but have never seen it.

I graduated in NH (NHCTC Stratham) in May of 2005. Took my boards June 7th, 2005. Could have tested sooner but I wanted a few more days to study. It is do-able, IMHO. Andrea

Clearly I didn't read your first post very closely! Somehow I thought you had said she was moaning with care.... Your other post about not being able to auscultate heart sounds, along with the wet breathing would lead me more toward fluid overload.....still, if she's that "wet", and even with no grimace but some moaning, I might use the morphine more often than q3hr.....

I'd rather suspect she is either in pain or anxious--anxiety may be r/t dyspnea. Is she on any morphine? I think she needs to be medicated!

I went to hospice directly from tele! Well, unless you want to count the 8 weeks of misery in outpatient oncology before I ran screaming to hospice (oh I loved onc--the patients, the work itself--it was the nastiness of the other staff I just couldn't stomach)... Actually, my experience sounds a lot like yours....spent five years as a unit secretary on tele, then was a new grad on tele--had just under two years as an RN when I went to hospice. If you've got any experience on your unit with palliative/comfort care only patients, that will be helpful.

I am going to respectfully disagree with that statement. Pain crises happen at all hours of the day and night. This is not a reflection on how well case managers are taking care of their patients. Otherwise, I agree with the rest of your post! Andrea

Can you ask to shadow for a shift before accepting the position? This would give you a better "feel" for the unit.....

I could not agree more with this post! It isn't that LTC nursing staff don't want to provide excellent end of life care...and obviously in many cases, they do. But given the LTC nurses' patient loads, and that the focus of hospice is really very different than your SNF patients....well, for all of those reasons having a hospice program in LTC facilities is a necessary adjunct to the care those residents are already receiving.

Welcome to hospice! I've only been in this specialty for five months, but I can't imagine going back to tele/stepdown now, at least not full time (I'm still per diem at the hospital). I do home hospice, and the acuity even in the home can be unbelievable--versed gtts, morphine and fentanyl and dilaudid gtts, tube feeds and ports to access....initally I worried about "losing skills" in home hospice, but in fact I feel like my skills are actually sharper now. (Especially with ports...I was always scared of 'em before!) Look forward to hearing more about your new position! Andrea

Road Notes is what we'll be using! I asked the question because so many of the RNs in my hospice are sooooooooooo negative about the change over--and I am personally looking forward to it! I came to hospice from a hospital with a fully electronic medical record, so going back to the reams and reams of paper, with stuff falling out of charts and missing or mis-filed....and not to mention often illegible...well it made me want to scream! I start learning the program next week.....can't wait!

I am curious, is your hospice using computer documentation, and if so, what program are you using? do you like it? If you have done both paper and computer documentation in the hospice setting, which did you prefer and why?? This should be an interesting discussion.....

I agree with this response as well.....my hospice job is much more flexible and family friendly than my 12 hour shift work in the hospital setting.

I refuse to believe that hospice requires us to be "on" 24/7. In fact, in my hospice I am encouraged not to even think of checking my email on my day off, or on the weekend. I am salaried at 32 hours per week, and yes, there are some weeks that I work more than that--but never more than 35-36 hours a week. My personal life is busy in and of itself, and I refuse to allow my job to eat into my valuable time with my family. IMHO, that work/life balance is even more important in hospice than in other areas of nursing, because as the hospice case manager, you already feel so RESPONSIBLE for everything that happens to your patients! I feel sad that you have a team leader that doesn't support you in this. Additionally, I think putting limits on call time is also a good thing. My hospice has a dedicated call team, but with some recent staffing changes, asked case managers to take some call--I took a few shifts I felt I could handle, but also made it clear that it's unreasonable to ask someone to work 8-430, be on call 4pm-8am, then come work another full day. If people are asked to take call then there must be some grace allowed to take a day off the next day (assuming the pager is going off.....if you have a quiet night, maybe it's a non issue). My point, I guess, is this: if you enjoy the work of hospice nursing, maybe this just isn't the right company for you? I don't know if you have other choices where you are geographically, but I'd encourage you to think about it at least.

We have a dedicated on-call team. I am currently obligated for one weekend of scheduled visits (8-430) per month, but our manager is in process of hiring weekend only nurses...which means my weekend obligation will be even less :)

That's tough. The main reason I chose nursing over another medical field I had been considering was that flexibility. I started out in telemetry, transferred briefly to oncology, and am now starting out in hospice. At some point, if I want to do telephone triage, case management, office nursing, ICU nursing, whatever--I can! THAT is the beauty of nursing for me. Yes, I put in my dues of nights/weekends/holidays, but my current job has very limited night/weekend call (because they have a great on call team), paid holidays, and I work 8-430, 4 days a week--per my choice! You aren't forever relegated to 12 hour nights as an RN either. I say, follow your heart or your gut....the hours will fall into place.

Hang in there! I went to NHCTC-Stratham, and the first year I applied I was wait-listed. I was #8 of 8. Although I never made it off the wait list that fall, I hadn't yet finished my pre-reqs anyway....so I used the time to finish those up. And then I was offered automatic admission the next fall. Plus, it sounds like you have other schools pending, so don't sweat it. You'll get in somewhere! Anyway, use your time now to bank sleep for when you ARE in school, lol! Andrea

I realize this doesn't directly address your situation, but on our floor we give po meds in the am before a dobutamine stress...with the exception, of course, of beta blockers. Yes they are otherwise NPO at least three hours prior, but so many of our cardiac patients need their meds! We don't hold them unless there are parameters that apply, or with a specific md order to hold them am of procedure. Now, depending on what time she came back, and whether any of those am meds were qday only or had other doses due, would definitely make a difference on whether or not I felt I needed to give them after the dobutamine stress. For example, if she had BID Lasix and she came back at noon, I'd probably non-administer the am dose and just give the pm dose. Does that make sense? Nonetheless, if you feel it was a med error you should document it as such, per your facility's policy. It happens. Take a deep breath. If that's the worst med error you ever make you're in good shape :)

I worked on a tele floor as a unit secretary/monitor tech while in nursing school. Never worked as an LNA. And guess where I started as a new grad RN? On my tele floor! If your interest is in cardiac or in critical care, I'd do the monitor tech position. If you're leaning more towards general med/surg, I'd take the LNA position. BOTH are good experiences, of course! But you'll get a really solid dysrhythmia foundation if you become accustomed to watching those monitors...just my .02! Andrea

Every onc job I see wants chemo experience and/or certification. How on earth am I supposed to get that? My hospital doesn't have an onc floor, and the opportunity to hang chemo on an inpatient on med/surg/tele comes along once in a blue moon.... The closest hospital with an onc floor is an hour away. The few jobs I've seen are 11p-7a, and I can't work nights--I can't sleep in the day,I know because I tried it as a new grad. Sigh. I'm so frustrated I could cry. This has been my goal since I was a nursing student, and I just don't see how to make it happen.