Shift nurses in Homecare, a question...

[hoolahan]

I am doing quality reviews for an insurance co, and I had a case where the mom of a child alledged the nurses gave her child a wrong dose of a med.

I read through 6 months of 487's, notes, etc...but I found the documentation very confusing.

In this situation, the child rec'd 7-3 and 11-7 nursing care. Parents did 3-11. So, there was no med kardex where nurses signed out daily doses, I guess because parents would not be expected to do so, and that makes sense.

I did find med lists, but they were very often not updated with the latest orders, and D/C of meds was documented only once out of 20+ changes. I never saw any documentation of dressing/treatment changes in the care plan, only on the 487, and when 485/orders updated every cert period.

Can you tell me how you track this info? I have to call the child's mother to see if she can give me a specific example of the errors she is referring to, but I suspect the chart has been sanitized. For example, there was one eve when the nurse documented she was refused access to the home. But no follow up call by a supervisor the next day? And mom requests a new agency with absolutely no indication of a problem documented? And a month of nurses notes is missing.

I see the mom signs the nurses notes each shift, so I can understand why nurses would be hesitant to chart negative social issues, but wouldn't there be some kind of documentation in the office record, if you informed your sup about a situation in the home? When I was a sup, I documented calls from the nurses.

I find it odd. What do you think? And how do you track med/treatment changes? What records do you keep in the home, and is there a duplicate record in the office?

[hoolahan, ASN, RN]

Thanks justbonny!! That was a big help. I am used to doing al my own orders for visits. Plus we don't have a daily medex, just a list we are supposed to update. A new med list is generated with any changes as per prior 487's every recert period.

[DaSuperRN]

Hi

I've never worked this type of nursing before, so I had this fear in the back of my head i.e. the one above along with many others. In the hospital and LTC we are pretty well protected. You speak of records i.e. could someone elaborate on all the records one should keep?

I will start; Nurses notes, medicine record, daily actitives record(a list of task we check off what we did each day)my work hour and pay slip signoff? Although, we were taught in school over (10 years ago)to document in narrative the dressing change we still have to check it of on a TAR. So should there be a TAR in home health?

I was told their was a care plan, thank goodness.

I will not do PEDS only adult, but it doesn't seem to be a lot of them in this agency.

Darcy :balloons:

[JustBonny]

Hi

I've never worked this type of nursing before, so I had this fear in the back of my head i.e. the one above along with many others. In the hospital and LTC we are pretty well protected. You speak of records i.e. could someone elaborate on all the records one should keep?

I will start; Nurses notes, medicine record, daily actitives record(a list of task we check off what we did each day)my work hour and pay slip signoff? Although, we were taught in school over (10 years ago)to document in narrative the dressing change we still have to check it of on a TAR. So should there be a TAR in home health?

I was told their was a care plan, thank goodness.

I will not do PEDS only adult, but it doesn't seem to be a lot of them in this agency.

Darcy :balloons:

Hi Darcy:

You need to read the Department of Helth recomendations for your state or the requirements of your payor (medicaid or insurance etc.) You must stick to the strongest set of regs that apply. In NY we need to keep all records (for adults for 7 years). Out records must include:

MD Orders, Med Administration Records, Nurses' Notes (only your own)

I&O (if applicable), Treatment sheets, The only difference between the chart the provider keeps and the chart in the pt's home is that you need only your own notes, not the other nurses. You do need all the MD orders of course, no matter who obtained them.

[hoolahan, ASN, RN]

DaSuper, I simplify ,my charting whenever possible, so if there is a check box for something, I will NOT write a narrative, it should be assumed that you are following your agencies policy, and that your competencies in that area have been regularly assessed as well. So, if I check "No signs and symptoms of infection" why write anything else about a healing incision?

My paperwork includes

Mileage record/assignment sheet

Consent form

Second payor form

HMO form if applicable

MIS, which is basically a computerized form of the referral, and beomes our "kardex", with history, emerg contacts, md's names and numbers etc...done on admit and updated prn

Med list

Oasis

485

carepath overview ( aka care plan)

admit note

carepath tracking form

HHA - 2forms; care plan and referral

PT/OT/ST/RD referral forms prn

Wound care baseline prn

For revisits

a note,update the tracking form, carepath, med list, wound care form, prn

487 prn

I have to turn in a carbon copy of each visit note with my mileage form, except new admits.

Our notes are very nice, 2 pages, virtually every single thing is a check box. In the open spaces I will add descriptions if needed. Fill in VS and BS in the blanks, etc... There is only 3 skinny lines for a "note" left. If you need to write a narrative, you need to put it on a progress note. I do not believe in double documenting. Only on an admit will I repeat things, since the OASIS will not make it to the travel charts for several days, so I want the next person to know what is going on. If the OASIS were to go into the chart on day one, I would simply write, "see oasis."

I have always gotten positive feedback about my charting, so I am sticking with this plan.