It’s no magic formula, but it might work
Try this agency’s documentation guidelines
A Petaluma, CA, agency decided it was time to update its nursing assessment and, at the same time, give nurses a refresher on documentation.
"We opened the inservice by saying that we wished we could give them a magical formula for documentation that would make everything simple, but we can’t," says Nancy Vedder, PHN, RN, quality improvement nurse for Petaluma Valley (CA) Home Health. The agency serves the California coast north of San Francisco.
Instead, Vedder emphasizes how documentation is an integral part of patient care, and it helps an agency meet these goals: cost effectiveness, regulation compliance, and reimbursement requirements.
Here are Vedder’s guidelines in teaching nurses about the importance of documentation:
• Remind them of the basics.
Vedder reminded her staff of the basic regulations that a Medicare patient has to be homebound. "A person is considered homebound if it takes a taxing effort to leave the home," she says.
"They’re allowed to leave for short intervals, but it requires effort to do so, and it’s rare if they do so."
Also Vedder went over the basics of documentation and told the nurses that it has to be consistent, concise, and measurable.
• Show how to do an initial assessment.
"We started out by telling them that it was an evaluation of a patient and it described physical, medical, emotional, nutritional, and the cognitive condition of the patient," Vedder says.
Petaluma Valley Home Health has its own two-page assessment form. (See Petaluma Valley’s assessment form, pp. 196-197.)
The form has checklists for 21 different categories and space for writing notes under four different categories. These categories include everything from functional limitations to hematological problems.
• Cover the care plan process.
Petaluma Valley’s care plan directs the agency’s patient care. It is started when the agency opens a new case. It is updated each time the staff responds to changes in the patient’s condition, Vedder says.
The care plan is on a letter-sized paper and includes categories for problems, goals, interventions, and outcomes.
Vedder has nurses focus on these issues:
What is the primary diagnosis?
What are the potential problems?
What problems require skill interventions?
• Go over the daily visit note.
"That’s the assessment for that day," Vedder explains. "They write down the problem they have addressed and how the patient responded to them and how they’re reaching their goals."
Vedder says the agency’s nurses typically do this very well, but there is a problem area.
"One area our nurses struggle with is the skilled observation and direct care," she says. "A lot of times they forget to write down the instruction they’re giving the patient."
For instance, a nurse might visit a patient to do wound care. So the nurse looks at the wound and tells the patient or caregiver how to take care of the wound and what symptoms to report to the doctor. But they forget to write down that they’ve provided this instruction.
"They need to document their teaching, and they forget sometimes," she adds.
• Discuss supplemental orders.
"We went over quite a bit how to resume a patient under a supplemental order," Vedder says.
If the patient is admitted into the hospital, and later the agency resumes the patient’s care, then Petaluma Valley Home Health has a new form, a supplemental order, to fax to the physician.
The inservice went over the criteria for that.
Other issues that would trigger a supplemental order are:
if the agency makes an extra visit because of a catheter malfunction or other problem;
if the patient has constipation or new symptoms;
if there is a change in treatment or a change in wound care;
if the medication is not working.
Occasionally these orders are overlooked, Vedder says.
The nurse will let the physician know if something new has occurred, and then they’ll follow the doctor’s orders and put what they did in the care plan. But perhaps they failed to fill out a supplemental order for the physician, she explains.
"Legally, if you get auditors coming in, and they see you’re doing things that you don’t have orders for, it doesn’t go over too well."
• Demonstrate how to do a discharge summary.
The discharge summary must be sent to all patients when their cases are closed.
"We discussed this for a while because people were unclear what we wanted as far as outcomes," Vedder says.
The discharge summary addresses what the final outcome was: whether the wound healed, what the patient learned, and whether the patient could verbalize what he or she was taught, Vedder says.
Nurses rewrite all problems from the care plan and rewrite all the outcomes on the discharge summary.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content