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Documentation
Documentation is a critical aspect of patient care delivery. Staff must effectively and accurately document pertinent information regarding our patients.
NURSE Documentation must include:
Assessments
Nurses Notes
Orders
Communication Reports with any change in patient condition including call in reports from field staff
Case Conferences
60-day summaries
Discharge summaries
Discharge Oasis
Complaints
MD Reports such as BP and BS logs
Supervisory Visits
New or Changed Medications- doc. on med profile and nurses notes
Modifications to the Plan of Care
Orders have to be filed on the chart for the following:
Admission Orders (Signed Copy of Admissions/Welcome Packet given to Patient or Patient's Representative)
Physician Orders
SOC (Case Manager Assessments)
Care Plan
Orders for all disciplines
Notes (Nurses Notes, Aide Notes, Interdisciplinary Progress Notes, Social Services, PT, OT, ST Notes)
Orders for all visits, if the nursing frequency changes, then a new order must be written
Order for all supplies
Lab & Special Reports
Wound Care
New Medications
Skills, procedure, and education (Patient Family Education)
Discharge Planning
Misc.
Note: Orders must be signed and placed on the chart within 30 days. All nurses’ notes must mirror the physician’s orders
HOME RECORD
At the time of Admission, the admitting nurse will leave a folder in the patient’s home.
The folder will consist of a patient calendar and vital sign log, as well as safety handouts, information on patient rights, and advance directive information. There will also be a patient education folder for each patient, that will be left in the patient’s home for their reference. For patients that are on daily logs such as weight, BP, or FSBS, please place the logs into their folders so all disciplines can access the information.
PATIENT EDUCATION
Patient education is an essential component of nursing. The nurse must provide the patient and/or caregiver adequate information about the patient’s conditions, medications, and all other care that is pertinent to their needs. We will provide the patient with an education folder at the SOC that contains all pertinent information and medication information for the patient. An extra copy will be placed in the folder for the nurse’s documentation. Please initial and date the education material that you cover to ensure that all necessary material is reviewed with the patient. Document the teaching and the patient /caregiver’s response to the education on the nurse’s notes.
If the patient has had a change in condition, new diagnosis, or new medication, then educate the patient on the new material as well as other material that needs to be reviewed.
CARE PLANS
If a care plan needs to be updated as a result of new or changed diagnosis or problem, then add the new nursing diagnosis to the POC using the nurse’s notes.
MEDICATION ADMINISTRATION
The SN can administer medications to the patient as ordered by the physician. Most patients do not require that a nurse administer the medications, but may need medication set-up by the RN. Medication set-up must be ordered at the SOC by the MD.
ADMINISTERING MEDICATIONS
Refer to the nursing policy and procedure manual for correct technique for medication administration.
All Medications that are given by the nurse must be documented in the nurse’s notes. Documentation must include medication given, route, dose, and patient response to the medication.
OFFICE SCHEDULING
It is the nurse’s responsibility to inform the case manager if anything changes with a patient’s POC. If a frequency change is imminent, then the employee must notify the case manager so we can better prepare to meet the needs of the patient.
FORMS
Nurses Notes/PT Therapy Notes
Missed Visit Reports- to be filled out by all staff if a visit is not made
Physician Orders- can be written by LPN but must be cosigned by RN
Fax Communication Sheets- used as a coversheet to fax confidential information.
Communication Forms- used to document any pertinent information regarding patient care delivery.
Time Sheet- used to document mileage and daily visits for payroll
Referral Forms- used to document new patient information
Oasis- comprehensive assessment performed by RN at SOC, Recert, Change of Condition, and DC for each patient.
New admit pack- taken to home for new patient admissions.
Case Conference- documentation that is sent to the MD at least q 60 days on each patient
Supervisory Visit reports- done by RN q 60 days on each LPN working with each patient and every 14 days for HHA.
Complaint Forms- form to be filled out by administration for all verbal and written complaints.
Nurses Bible to Home Health Documentation
Documentation is the hardest concept to grasp in home health care. There are so many things to remember to document. Therefore, we have put together a “Bible” of useful documentation tips that will make your documentation a little easier.
NURSES NOTES:
Vital Signs
Document complete set of vitals each visit. If not normal for patient, then notify MD for new orders
Blood Sugars
Document values, whom performed test, time of test. (e.g. 112 per SN @ 1200)
Medication Changes
This has to be verified each visit. If the meds have changed, you must update both travel chart and office chart and write a doctors order for the new medication. Include a diagnosis for the new medication. This applies to both OTC / Sample medications. (e.g. Telephone call from MD to patient. Change ___ to ___ effective (date of change) Dx ___)
Homebound Status
The admitting nurse will identify the reason for the homebound status. This reason is carried with the patient throughout the certification period.
Homebound status has to be assessed at each visit for Medicare patients. If the patient is a Medicare patient, they have to be homebound. If you think a patient is not homebound anymore, please notify the case manager.
Head-to-Toe Assessment
To be done on all patients each visit.
Cardiovascular
Check appropriate boxes:
Are heart sounds regular or irregular, are there extra sounds noted
Document radial and apical pulses
Document whether the pulses are strong, weak, or absent
Document any edema, and/or comments
Respiratory
Check appropriate boxes:
Document if lung sound clear or adventitious (if adventitious document the sounds)
Assess for cough and describe if present (wet, productive, non-productive, frothy)
IF the patient is on oxygen, document the flow and delivery system
Document the pulse ox value if ordered or the patient presents with dyspnea
Neurovascular
Document orientation status. Check all that apply:
If the patient has a memory problem that is considered to be a functional limitation. Add forgetful to the neuro assessment. If you check pupils for responsiveness, then document.
Sensory
Document deficits and acids used to correct or assist the deficit. Otherwise, document, WNL (hearing aids, glasses)
Genitourinary
Assess and address category appropriate to the patient. If the patient has a catheter, be sure to document what type, size, balloon cc amount, amount of urine in bag, color, and odor. (Obtain specimen if ordered, then empty) If the patient is presenting with anything not listed, address it under the GU section.
Skin
Document if the skin is warm, dry, moist, cool, or clammy. Document if the skin color is pale, mottled, cyanotic, or normal under comments. Document if the turgor is adequate.
Wound
If the patient has ongoing wound care, then use the wound care flow sheet each visit. The number of the wound will be the same number as assigned by the nurse who identified the wound. Additional information will be addressed on the wound care flow sheet. You do not have to document that the dressing was change. This is documented on the wound care flow sheet. All wounds must be measured at least once weekly and preferably on the same day of each week. When a wound is healed, document in the visit record the location of the wound and that the wound is healed and an order is written to discontinue wound care. However, continue to address the wound as healed on subsequent nurse’s notes.
If caregiver is performing wound care, you can document this in the skin comment section.
Digestive
Document the last bowel movement. Assess for the present of bowel sounds.
Diet
Document diet on the 485, if the patient is on a special diet then document diet recall to assess for compliance.
If the patient has a feeding tube, check for residual and placement each visit. (This requires a MD order so make sure that order is on the chart. If not, write an order for SN to check for feeding tube patency and residual prn, and report any abnormalities to MD.)
Musculoskeletal
Assess and address all that applies to the patient. (c/o weakness, balance/gait problems, pain). If the patient has a disease that can affect grips such as CVS, assess and document grip strength. Document any assistive devices such as walker, can, wheelchair, and scooter.
If therapy is involved, then document that therapy is seeing patient in comment section.
Pain
Document completely. Medicare loves this section! If the patient denies pain at visit, then document no c/o pain at present time.
Infusion
Mark each area that applies. IF the patient is not receiving infusion therapy, then mark out infusion area.
Skilled Intervention
Always start with primary and secondary diagnosis. SN assessed all body systems and vitals. Then document the condition of patient upon your arrival including any complaints and updates from patient including MD appointments, new meds, etc. Address as needed in the note. Teaching should be done at each visit. This is a skill. Teach the disease process during the early period of certification, followed by medication, then other associated care. If new meds are started, then educate on the new meds. Document all education (SN educated patient/cg on…) Make sure that what you teach is measurable. Then document the patient’s response to the education such as through direct observation of a skill you taught, verbal understanding of side effects, etc.
Supervision
All aids must be supervised by a Nurse every 14 days if nursing care is also being provided. This is done on a separate form, which has to be signed by the patient. Document both the employee name and supervising nurse.
Coordination
Goals: Document what the goals are, how they are being achieved and progress/regress toward goals. (e.g. patient able to state side effects of Coumadin.)
Teaching: Document the subject you taught on the Title of Teaching Tool area in the nurse’s notes. Handouts are excellent, but provide an extra signed and dated copy with your notes.
Physician Contact: Contact physician for condition changes, abnormal vitals, act. This is mandatory for Medicare regulation.
Order Changes: Telephone call to MD office, spoke with nurse. SN to…
Plan for next visit: If you are the primary nurse, then specify what will be taught; otherwise, assessment and education are acceptable.
Discharge Planning: Document that the patient will be discharged when skilled care is no longer needed. Or, document that you have discussed pending discharge on patient who are in the last week of their certification period.
Update to Care Plan
If you update the care plan, then notify the case manager so a case conference can be help on that patient.
Signatures
The nurse will sign name and title. The patient will sign stating that the visit was made.
Time/Date
Document time in/out (this must be at least 30 minutes) and document the date of the visit.
Time Sheet
Place visits on time sheet and turn in to the office within 48 hours.
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