Travel charts

[twokidsmom,rn]

I have been working in HH for almost 7 months now. Still working on organization and what works best for me.

My company does not use computers but do have some forms that can be typed. My handwriting is very bad so I have been writing daily notes then at night typing them out and saving it to my computer. It has been working well BUT I have not been making 2 copies. I do have them saved to a flash drive and I write notes on the file folder and I bring the file folder into each visit.

My question is when medicare reviewer does there visits with a nurse do you have to show them your travel file? We do have charts in the office where all the daily visit notes are stored. I am the only nurse who types my notes others write them.

If a Medicare reviewer comes out with a nurse and I am doing something they do not like or I missed something what can happen to that nurse? For example if a PCP ordered a new med and it is not listed on the med list in the pts. home or you did not get a signed verbal order of a new med change.

I feel that I have not had a great orientation and I do alot of trial and error. I went out with a nurse for 1.5 weeks before I was on my own. My manager has said she plans on doing some visits with me one day, but has not yet. And has asked me what do I need, the thing is I don't know what I need I just keep going day by day and doing the best I can. I see 6-10/day mon-fri I have been seeing 1-2 on saturdays for the last 3 weeks too. I have to be oncall one weekend a month too.

Any advise would be helpful.

[caliotter3]

You know, until your supervisor gets involved, or you come upon what you believe to be a better system, I would continue as you are doing. So far it is working for you. Should you be told otherwise, then make the changes. But don't put more work on yourself at this point unless it is your idea. If what you are doing is so far off base, then it is up to your supervisors to let you know. They should have done so by now, so it is not high priority to them.

[cathrn64]

I have never been asked to show my "travel chart." Which is good, because I don't keep them. I know a lot of people do use them. As long as you protect them from view and don't bring other pt's charts into homes, you should be OK (HIPPA) As far as the home chart goes, try to keep it up to date and be sure to get orders for those new or added meds. Keep in mind that the surveyor is looking very hard for anything missing, and will probably find something! They will go with more than just one person, and look at charts in the office. At the end of their time they will go through what they found with the supervisor

P.S. 1.5 weeks of orientation and 6-10pt's a day? = bad company!