When do you document

Posted

I see 8-10pt/day that may include a recert or open. I have been writing then coming home and typing my notes because we do not have computers any my handwriting is very bad and have had too many complaints so I just type them. Yes it takes me around 2hrs a nite.

But if I do it this way then I don't have as much on the weekend as long as I keep up every night. I still end up doing odds and ends and getting ready for the next week on the weekends but about an 1-2 all weekend.

But I also work one weekend a month.

Wondering what others do? We have a nurse that ends up doing all paperwork on sundays but she writes notes in the car after visit.

Isabelle49

Isabelle49

Specializes in Home Health. 849 Posts

I document as much as I can in the home, especially anything that is out of the normal. I have always finished the notes at home. For OASIS, I do pretty much the same. I do spend a considerable amount of time completing notes, this morning 2.5 hours = 2 admits and 5 regularl visits, plus on the phone to the company off and on. I hate paperwork and when I retire I will ban pens in my home, lol.

Sugarbear55

Sugarbear55

23 Posts

Every night from 7PM to around 11PM.

paddler

paddler

162 Posts

I document almost everything in the home, and usually the narrative later as it takes some time to make an intelligent sounding visit note and I cannot seem to do this while paying attention to the patient... go figure.

berube

berube

214 Posts

i also do what i can in the home, then spend time later doing the narrative so i can concentrate, but i do alot of my charting at the end of the day at home.

paddler

paddler

162 Posts

Also, It sounds like your Agency charts on paper? You may want to consider going to an agency with computerized charting (if you can) so that you can chart in the home, and not have to type out your notes at night... I just re-read your OP and originally missed that you don't chart as you go (on paper I assume), because of your penmanship.

twokidsmom,rn

twokidsmom,rn

198 Posts

I write quick notes on the form then type them at home because of my penmenship. Truly wish my agency would get with the times and get computers! It would be better for everyone, could print out a nice med sheet and print out information on each med.

homehealth_rn

homehealth_rn

26 Posts

I also try to document as much as I can in the home. I like to chart everything except the narrative in the home. If it's a nasty, stinky home, then I just make notes and chart at home and it's usually at night after my child goes to bed. If I don't chart in the home, I end up forgetting details.

NissaNurse

NissaNurse

Specializes in Geriatrics, Developmental Disablities. Has 10 years experience. 39 Posts

Well my agency wants us to do our charting with our system but will not supply us laptops, so what I do is I take notes in the home and then once home I log into my account and enter my noes but it would be so much better if I was able to do the charting in the home, but like I said we don't have laptops an I don't have one and won't be getting one anytime soon.

Isabelle49

Isabelle49

Specializes in Home Health. 849 Posts

Sounds like your agency likes freebies!