Start your documentation with this program
January 1, 1997 3 minutes read
Start your documentation with this program
An organized 5-step plan helps
Documentation is no fun. Just ask your nurses. But you can succeed in convincing them of how important changes are in the way they document their patient care if you follow an organized inservice plan.
Alpena General Hospital Home Care Services of Alpena, MI, turned its inservices on documentation into a five-part series held over a five-month period that was mandatory for all nurses. This information also is included in each new nurse’s orientation. The agency covered the following five main areas:
1. Discuss the coverage of services, billable vs. nonbillable care and the Medicare 485 plan of care.
"The nurses need to understand that the discharge planning process starts on admission," says Mary Jo Skiba, RN, BSN, performance improvement/marketing coordinator.
Based on Medicare guidelines, the nurses are taught what needs to be on a 485 plan of care and what is going to improve the quality of care, Skiba recounts.
2. Explain the 485 plan of care work sheet and how to write meaningful orders and goals. Also, discuss patient outcomes.
The agency has started to use hand-held computers for the plan of care and goal setting and has found this to work splendidly, insists Sandra Purol, RN, clinical supervisor.
"It’s all problem-oriented. When you identify and enter a problem, it all pulls together from there," she says. "You can create your care plan from the problem, and you can make it very specific to each visit."
3. Emphasize the initial nursing assessment and what to include in the admission summary.
Purol and Skiba also discussed the nurses’ note format and how nurses can write problem lists using approved nursing diagnoses. They touched on how to document findings, interventions, and patient response to care.
"We felt like we needed to cover what was in the plan of treatment and make sure they understood that," Skiba says.
"When you do your initial assessment, that’s when care planning starts," she adds.
4. Explain how nurses are required to establish a problem list, and write a sample nursing note using the new format. Also, review home health aide care planning and writing up the assignment.
Skiba and Purol gave nurses a case scenario and included guidelines for how they could fill out the nursing note.
The nurses had to document the patient’s response to patient teaching and any changes. "We still kept a checklist, but we changed it to more of a problem-oriented nursing note," Skiba says.
"After we went over the guidelines, we went over why we had to do these things, and we had them fill it out and turn it back in for practice," she explains. "They picked up on it quite quickly."
5. Discuss the documentation dos and don’ts.
They touched on the following topics on the final day of the series:
• rights and responsibilities;
• initial nursing assessment;
• emergency plan;
• medication profiles;
• nutrition assessments;
• diabetic clients;
• standardized orders;
• update summaries;
• verbal orders;
• calendar use.
After the series ends, Skiba and Purol suggest home care supervisors meet with staff individually.
"The nurses would bring their notes back to us, and we went over them," Purol says. "If there was something not quite clear, we would ask them about it."
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