Tips for working in the field

mschelee, MSN, RN · Jul 22, 2010

i would be interested in this advice too. :idea:

annacnatorn · Jul 22, 2010

Anyone willing to share tips for working in the field seeing hospice patients at home, SNF, or short-term inpatient?
-How you organize your day/ prioritize your cases/ keep your recert preparation on track/ communicate optimally with caregivers/ review documentation before submission to IDG and medical records etc.
I would love to be able to take what you are doing that is working very well and incorporate it!
Thanks!

Although Not an RN yet, I've been around many and have learned a ton of information from each one of them and have utilized the information when out on my own...

Organize: we try to do patient visits in order of who is furthest, but only in a perfect world. you have to see who is most critical first. Usually new admits require a second visit a few days after initial admission, to clarify information given to them. At admission, so much info is given, families often get confused and have more questions to ask as a day or two passes.

Carry extra supplies. It is better to have 2 catheter kits in your car then to not have any, because you will use one and then need another before you go back to the office. Keep extra supplies in your car, gloves, creams, lotions, f/a stuff, wound care stuff, sharps container, E-kit (depending on your Agencies rules for this one) Diapers, chucks.

Recerts are done: 2 90 day periods, then subsequent 60 day cert periods. You keep track of the dates of admission and count 90 days..do a recert (get it?) For Supervisory visits for the LVN and CNA..LVN I believe is 1 every 30 days, CHHA is one SVO (observation) every 14 days (two weeks) SVF (follow up) ever other 14 days..so week 1 is nothing, week 2, SVF, week 3 SVO, week 4 SVF (your reg nursing visits can be done at the same time as SVO and SVF.

Some of the Nurses I have shadowed have made notes in a note book, then transcribed them to the standard forms, others have done the notes directly on the forms at the time of visit.

Review your notes prior to turning them in, keep copies of your notes, just in case the ones you turned in get lost, also keep copy of your visit log sheet (we/ I have learned that MR looses stuff....I got to a point that I made copies of the notes and route sheets, then had MR sign my copies that x number of pgs were received..when I started to do that, amazingly none of my notes nor the RN's got lost!)

In the Home, document everything you told the Fam/PCG.

In the SNF..document like your butt depends on it. better to over document then underdocument..CYA...same with short term inpatient.

Carry Water and non perishable healthy snacks in your car.

Keep your cell phone charged, carry your charger.

Keep your phone updated with all of the necessary numbers you will need, Admin, DON, Office, fax office. MD, Alt MD., Pharmacy, DME, Fellow Nurses, and Support staff ie, Chaplain and MSW.

Extra forms all of them.

If you do admissions, then make sure you have extra admission forms especially on the weekends...Don't get caught with out, it never fails, when you are out of what ever, that specific item is needed.

Carry a Pulse ox. and extra batteries

carry a digital thermometer

BP cuff, if you use digital, extra batteries

your watch..ok I know you know this one!

extra black pens.

your ID.

Hope this helps..any more questions, dont hesitate to PM me! I may not be currently physically working, but my brain is all about Hospice.

Welcome to an exciting and most rewarding adventure!

mschelee, MSN, RN · Jul 22, 2010

questions that come to mind:

How do your start your day in case management? Ie check phone messages ect.. Do you alway go into the office first? ect...

volsfan · Jul 22, 2010

An average day:

7:15-7:30 See first pt of the day (I like to get started early, you will find if you start prior to 8 AM it works better)

Work until 1030-1100 seeing pts. Take a break for lunch, b/t 15 minutes to 1 hour. Depending on if eating with coworkers or took my lunch

1200-1500 Finish up seeing pts and/or go to scheduled meetings.

1500-? Go home and finish up any documentation needed.

I see most of my home pts twice weekly; carrying a caseload of 15 pts on average and average 5 visits per day. My home pts know I will be there on what days and around a certain time of day; such as early morning, mid morning, midday, etc. I always call if I am going to be "late" and let them know I have been delayed. So, if I have to bump a pt from early morning to midday I certainly call. When I get a new pt on service I fill them into a open spot. You have to be flexible in this job. You will get to know which pts you could even bump to a different day and which ones you just need to keep on schedule.

If I have a cont. care case going I make a call first thing to see how they did overnight. If they are "comfortable" then I fit their daily visit in based on location; if not then I will see them first thing. If your company doesn't do CC cases, but you have a pt not doing well I would do the same thing.

I agree: carry extra supplies, restock as soon as you run low; extra forms organized in a binder; program all numbers in phone including pts. I put pt and then pt name so when I scroll for the name it is easier b/c it goes straight to all the pts. Example: Pt Smith

Recerts: We are lucky that we are on computer, we have a screen that tells us when the next one is due. My old employer did not, but during all Monday morning meetings we were given our census printed and it told us any upcoming recerts that would be due. I always turn them in 1-2 weeks prior so they can get them signed. If you don't have those luxuries I would get a calendar and on admission of a new pt put in their recert dates, going out 6 months or so. Even better would be using MS Outlook and doing a recurring event. That way when they die/revoke/discharged you can just delete the recurring event and not worry about missing something. And you wouldn't have to count.

Well, I have much more, but got to get my day going!

tewdles, RN · Jul 23, 2010

In our neck of the woods many if not most patients do not want their first nursing visit before 0900. So most of us start out in a facility if we want to visit early. As well, I find that I am visiting patients at 5 pm or later several times monthly because the DPOA or first degree relative wants to be present but has a work obligation, this is fine with me...I just start later in the day then.

I begin my day by reviewing the calls to our triage and on-call team from the previous night. Any patient on my team who contacted triage/on-call will minimally be called by myself or the team LPN first thing in the AM. I review my internal communications, emails, and voice mails before I have any patient contact. I accomplish those tasks from home. I do not go to the office most days unless I need supplies, etc. We have an electronic patient record.

My schedule for any given day is pre-set (by myself) in the days prior based upon my assessments, Dr. orders (ie:time/day sensitive labs or procedures), or patient requests. My daily schedule may start out as ABC in the AM and turn into ADFQR by 3 pm.

I schedule patients based upon need and location. So, if I have 4 patients in the same community I will make every attempt to visit those 4 on the same days, more or less, and according to patient/family status. I try to start with visits closer to my home and end with visits closer to my home...so in essence I try to make a loop.

It is a good idea to practice completing the documentation at the time of the visit...point of service documentation. This will accomplish several things...first it will make your employer very happy, second it will minimize the possibility that you will forget something, and thirdly, it will minimize the amount of personal time stolen by work.

I make and review notes for my IDT presentation at the time of each visit. My IDT presentation is 100% related to the POC and the problem list (NANDA based). I report on any changes to the POC or problem list which have occurred in the previous 2 weeks and comment on new problems, interventions, or goals, resolution of goals, patient response to interventions, and any concerns or questions that I might have...etc.

I generally try to have a very light visit schedule on IDT days...I go to the office early and review my visits and IDT notes for the past 14 days. I make sure that I have written MD orders as needed (you know, the verbal that you got while you were driving in heavy traffic in the rainstorm on the highway)...I review the med lists for each patient to insure that it is up to date for IDT scrutiny.

Recertification dates are calculated by our software, so they are easy for the case management staff to access independently. However, our management staff also email us the list of patients who will be due for recert discussion...we receive this at least 7 days prior to the meeting. Remember that recommendation for recert must be objective and measurable...so review the guidelines for your patient's hospice diagnosis.

After IDT I will generally have at least an hour of follow up work, dependent upon the complexity and size of my case load.

Because we have an electronic record I do not need to stock forms except those which the patient may require...

so I keep a stock of revocation forms, 48 hour Medicare NON-coverage forms, DNRs, etc.

good luck

Hospice Nurse LPN, BSN, RN · Jul 24, 2010

Wow! You ladies covered nearly everything I could think of. The only other thing I could think of is my phone is MY PHONE! Even though my company gives me a $50 phone allowance, I do not want pts or family members calling me directly. We all stress the importance of calling the office number after hours and weekends. I enter all my pts (and family members) numbers in my phone. Then when one of them calls me directly I can choose to ignore the call. My voicemail msg says, "Hi. This is Sharon with (company). Please do not leave me a msg about a pt as I probably will not call you back. Please call the office @ **** and the answering service will contact the nurse on call. Thank you."

I used to allow pts and family members call me directly. About 5 years ago I was on vacation out of state and my phone was in the hotel room charging. When we returned late that evening, I had five msgs from a family member about his grandmother declining rapidly. The last msg, left about 15 minutes before we returned to the room, was that the pt had died. I called them and told them I was sorry and would contact the nurse on call for them. After that, I changed my voice mail msg. The agency I work for now actually will give a verbal warning for any employee giving pts their wireless number.

mschelee, MSN, RN · Jul 24, 2010

This is all such good advice.

Cardiac-RN · Jul 24, 2010

Thanks everyone for all the great info!

ErinS, BSN, RN · Jul 27, 2010

I case manage and do my own admits, since we are currently short staffed. my days usually look like this:

8-9 I meet with the other nurses I work with and begin to figure out my schedule.

9-10 I gather supplies and visit the pharmacy (I deliver most of my patients hospice meds to them)

I then start my visits. I visit my GIP (usually in the hospital) patients first. Then I continue on to my regular visits. My smoothest days are when I can see my east side patients on Mon and Thurs, west side Tues and Fri, and fit others in as needed. This often ends up being 5-8 visits a day. I am usually done with my visits by 3 or 4 and then can do admits in the afternoon.

I do not always have smooth days, but as you know your patients things like recerts and med refills become easier to keep track of. We do not have lpns, so I am only responsible for supervisory visits on my aides. I have one aide I am responsible for and she sees all my patients. I do visits with her several times a week.

My best advice: do not feel bad if your day goes to heck and a handbasket by 9 and by 10 you know that you will not get to most of your patients. I work with a great team and I use my chaplain and social worker to provide support to stable patients when I am unable to see them. I always call my patients when this happens and make sure they have no changes and everything is okay, along with when I will see them. There is a reason patients have an interdisciplinary team, and we are here to help each other. Also, I pray a lot during my work, and I am not a very religious person, but I know God is looking over me, at least most days. Good luck!