Documentation for Home Health Part 2

Maybe They Do Not KNOW What To Write!

As worried as I have been over the last few days about having to apologize for doing my job; it finally dawned on me that perhaps the ruffled feathers was not because I am new and they are not used to being audited; perhaps it because they quite honestly do not know medical surgical nursing and are blustering to cover up their ignorance!

It seems crazy, I know, but lets face it, I was there once.

I know how scared I was when I didn't know how to teach a person on celiac disease! I had never taken care of a celiac patient before! I had to go look it up! I did it BEFORE I went to see my patient of course but that first instruction was mostly read off the paper I had copied!

After that I knew I better start learning and I better act like I knew what I was doing or the patient would likely call my boss and say "Where'd you get this yahoo and can you take her away and send me a REAL nurse?"

Being in the south, that would be the most likely thing to happen too!

So I wrote up a cheat sheet on different disease processes, not many, just to see if the staff will take to it and actually use it in their notes! Tell me what you think of it.

One example

Cheat Sheets for Instructions

Of Course, the use of our teaching guides is a lot easier than this BUT

First of all let me say that we appreciate all of your hard and excellent work, we just want to make sure all bases are covered and that your documentation reflects the good care you are giving and supports the need for skilled care.

Concerning the nurses' note itself be sure you follow the format, write on every line, print if your handwriting is not legible, use a communication note if you cannot fit it in the format. You cannot write a narrative that covers the intervention and goes on into the instruction and progress of goals within the back page of the note itself. You must stick to the format of the nurses note itself or else we are out of compliance with our own process.

Here are some basic cheats for our most common disease processes. I am sure you can add to this on you own, the use of note cards was a good way for me to learn all the instructions of different disease processes . Personally I thought it was a great deal when we finally got teaching guides, saved my hands from writers cramp for sure! But if you don’t use the guides then you have to write out exactly what you said to your patient so here are a few for your use.

COPD

Is a lung disease consisting of chronic bronchitis and emphysema. It causes the alveoli at the end of the tree like branches in your lungs to harden and makes breathing difficult. Increased mucus with coughing is one of the first signs of COPD. Cigarette smoking is the most common cause of COPD so tobacco cessation is the most important thing you can do. Medications, the use of oxygen and respiratory treatments will help make you more comfortable.

Another important thing to remember is infection control. Persons with COPD are more prone to infection, so avoiding persons who have a respiratory infection and washing well and frequently is paramount. Hand washing is the single most important way to prevent the spread of any infection. Handwashing should be done before and after going to the bathroom, before and after eating, before and after taking medications as well as after coughing up mucous. Dispose of tissues in garbage immediately.

Get your pneumonia vaccine as ordered, usually every 5 years and get your flu vaccine yearly.

Signs to report of complications of COPD include change in the colour or consistency of mucous. Mucous with COPD is usually white and frothy. Increased shortness of breath not relieved with the use of puffers or rest. Increased temperature, chest pain and fatigue can often be signs of a lung infection.

Correct way to use nebulizer

Nebulizer treatments are often used in COPD or in other lung infections on a short time basis such as pneumonia. However, if done incorrectly it will not be effective and the medication will not be able to work and help you feel better. Nebulizer machines use gentle pressure to help move the medication into your lungs but you must do the rest of the work. Sit up straight, hold the mouthpiece firmly in your teeth, breathe deeply, and hold the medication in your lungs. You should never puff the medication in and out quickly like smoking a pipe. Take a deep breath into your lungs as deep as you can and hold it as long as you can then let it out slowly and repeat this process until the medication is completely evaporated from the little cup.

An important thing to remember about the use of nebulizer treatments is infection control. Every part of the nebulizer should be broken down after every use, cleaned with warm soapy water, rinsed with clean water and set out on paper towels to air dry. When dry, store the pieces in a zip lock bag until the next time a treatment is needed.

Correct way to use inhalers

Spiriva is a powder that comes in the form of a capsule. It has a special container that when you twist it to open will show four small pins that will pierce the capsule to release the powder. Place the capsule inside the chamber and twist the container back to the original position. Hold the chamber firmly between your lips, push the buttons on the side, and inhale deeply. Only push the buttons once. The pins will pierce the capsule when the blue buttons on the side are pushed. Turn the chamber over and inhale again with your head tilted back. You will taste a sweet taste and hear a whirring noise. If you get pieces of the powder in your mouth, it will not hurt you but this may be due to pushing the buttons more than once. When the capsule is completely empty, take it out and place in the garbage. Sometimes it takes more than twice to empty the capsule completely

If you are using an aerosol inhaler, the important thing to remember is to keep the chamber at a 90-degree angle with your face, hold the mouthpiece between your lips lightly and inhale as you compress the aerosol. Hold the medication in your lungs as long and deeply as you can before exhaling and wait at least 3 minutes before taking the second puff. Some inhalers contain a steroid and it is important that you rinse your mouth well after use to prevent mouth sores and or fungal infections such as thrush.

Nutrition for persons with COPD

Persons with COPD get short of breath easily and especially while trying to eat. At the same time, just trying to breathe causes them to lose calories at a faster rate. It is important to eat small frequent meals that are dense with calories. This will help with your metabolism and keep you from getting short of breath trying to eat a larger meal three times a day.

HYPERTENSION

Persons with hypertension have stage one heart disease. It is caused when the heart is not able to move the blood efficiently around the body due to increased pressure on the vessels. The top number, systolic, of your blood pressure shows what your heart is doing while you up and about expending energy. The bottom number, the diastolic, shows the pressure your heart is under while you are at rest. So that is why nurses especially become concerned when the bottom number gets high or gets too close to the top number. It means your heart is under a lot of pressure just trying to move the blood from one place to the next in your body. High blood pressure, left untreated, can cause heart attacks and strokes.

Signs to report include nosebleeds, severe headaches, and blurred vision.

Ways to prevent complications include eating a well-balanced meal with plenty of fresh fruits and vegetables, avoid the use of salt as well as the use of salt substitutes as they contain potassium, use of herbs with cooking and exercise as able. Avoid red meats, avoid fried foods, avoid processed foods and junk foods; grill or bake meat and add chicken and fish to your diet in limited amounts. If you use canned vegetables, you should pour off the liquid from the can and replace with water, avoid frozen vegetable as they are preserved with salt and contain more salt than canned foods. Walking is the best exercise and will help maintain a healthy weight, which in turn will lower your blood pressure.

Take the medication prescribed by your physician as ordered and maintain a written log of your blood pressure is also of great help for your treatment. Take your BP regularly and take the written log as well as all your medications with you for every doctor’s appointments.

CONGESTIVE HEART FAILURE

Congestive heart failure is a form of heart disease where fluids build up around the heart and the heart is unable to effectively pump the pump to and from the lower parts of your body. Your heart is very selfish; it will take care of itself and the surrounding area. But once the blood and fluids get down to your legs and toes the heart will not go out of its way to get it back up to your lungs. That is why your legs and feet swell up especially if your sit in a dependant position all day. Elevation of your legs at rest is imperative as well as walking. The pumping action produced by walking helps get the blood and fluids back to the torso where it can be distributed again by the lungs and heart.

Ways to manage include avoiding salt, elevation of legs at rest, taking medications a physician orders, and exercise as able, sleep with your head above your heart. One use of condensed readers digest books is to put them under the posts of the front of your bed so you can breathe easier at night!

Signs of complications to report include waking in the middle of the night unable to breathe. Increased urination at night is a sure sign that you should see the physician quickly. Increased weight of 3-5 pounds in a day or over a week means you need to see you physician. Increased difficulty breathing, changes in the colour or consistency of mucous and increased coughing

Weeping of fluid from lower extremities often accompanies persons with CHF due to the fact that the fluid has no way to get back to the top of the body and it will come out through the pores of the sin. Left untreated this can lead to cellulitis, open sores and systemic infections. It is important that you help prevent this by elevation of the legs at rest, keeping the skin clean and dry as possible, avoid scratching or hitting your legs and seeing your physician at the first sign of weeping of fluid from your legs. Prevention of secondary infection is important so hand washing is imperative. Hand washing is the single most important way to prevent the spread of any infection. Wash your hands well and frequently for 20 seconds with soap and water. Wash your hands before and after eating, after using the bathroom, and before and after taking medications.

Cellulitis

The skin is composed of dermis, epidermis and subcutaneous layers. When an infection occurs in these layers it causes a red, sometimes itching, hot painful infection called cellulitis. It can cause increased temperature, chills and muscle aches. The reddened area grows and spreads quickly and left untreated can cause a systemic infection, meaning it can spread into your bloodstream.

Cellulitis is treated with antibiotics sometimes both by mouth as well as topically and sometimes wound care for open areas may be needed. The most important thing to do is to keep your hands and the area of infection as clean as possible. Hand washing is the most important way to prevent the spread of any infection. Wash your hands well and frequently for 20 seconds with soap and water. Wash your hands before and after using the bathroom, eating and taking medications.

Signs of complications include worsening of cellulitis like open sores, changes in the colour of drainage, if any, increased pain, warmth, redness or spreading to another part of the body. Cellulitis occurs most often on the legs and legs.

Cellulitis is a bacterial infection most often caused by staphylococcus. This and all bacteria are on and around us all the time. When the bacteria cause problems is when it gets into our bodies such as through a cut or a break in the skin. Cellulitis can most often be traced back to a trauma such as cut or a scrape.

Coronary Arterial Bypass Graft

Coronary arterial bypass graft is done when there are blockages to the heart and leads to chest pain or a heart attack. A blood vessel is often taken from the leg and used to bypass the artery with the blockage going to your heart. You will have to monitor this are on your leg or both legs, depending on how many bypasses are needed and make sure this area heals without infection. Sometimes the area just above the knee or just below the knee will open and weep and may need to be dressed on a daily basis or kept clean and dry with soap and water and left open to air if there is no drainage. Notify your nurse or physician immediately if the areas on your leg open, weep, swell, have pain or drainage of any kind. You will also have two or three areas on your abdomen where drains were placed and often the ones under your breasts take the longest time to heal, as they were deep and wide. Monitor these areas as well and make sure they do not have surrounding redness, warmth or pain, The area on the mid chest will take the least time, usually, to heal and may itch but do not pick or scratch at this or any of the areas. Prevention of infection is important. Hand washing is the most important way to prevent the spread of any infection. Wash your hands well and frequently for 20 seconds with soap and water. Wash your hands before and after using the bathroom, eating and taking medications.

The most important part of recovery is with your own mindset. You have a brand new plumbing system for your heart but if you do not change your lifestyle, you will be right back where you started before long. Diet is the first thing that must change. Decrease the amount of red meat, eat more chicken and fish, grill or bake your meat and increase the amount of fresh fruits and vegetables. Drink plenty of fluids, especially water, up to six to eight glasses a day. More important than any of this however, is walking. Walking is the best exercise after heart surgery . The physician may refer you to cardiac rehab and this is an excellent way to establish a routine for physical activity following open heart surgery.

Wound care

The objective for all wound care is the healing of the wound without complications. A secondary infection can cause disruption in the healing process and added suffering. The first sign of infection is always pain. The body will tell you when there s a problem and pain is always first. Other signs of complications include redness, warmth, swelling, increased drainage, foul odor and increased temperature. Hand washing is the most important way to prevent the spread of any infection. Wash your hands well and frequently for 20 seconds with soap and water. Remember to sing the ABC song or Happy Birthday as you wash your hand. These songs usually lasts exactly 20 seconds! Wash your hands before and after using the bathroom, eating, performing wound care and taking medications. Keep your wound care supplies in a plastic bin with a closed cover away from children and pets.

How to write your wound care skill itself

You must be specific and you must follow precisely the way the wound care order was written and if the physician orders any wound care changes your documentation must reflect these changes. So the starts of the skill start with the writing of the physician order itself. Although the physician may be short and sweet your writing of the order must reflect the diagnosis, all supplies and the frequency as well as who will be performing the wound care itself. Written correctly, the order can then be written in every nurse’s note without problem and you will always be in compliance with the doctor’s orders for wound care. Always be sure to double check the wording of the written order before you write it in your note! Keep the order as generic as possible, if you say kerlix it must be that name brand, better to say rolled gauze.

An example may be as follows: wound care to__________site performed as follows: site cleaned with normal saline, pat dry, applied aqua cell AG, covered with gauze, secured with tape, patient tolerated wound care without problem, waste disposed of properly. Caregiver to perform wound care on day’s skilled nurse is not present.

Another example may be for the use of vac pack. Using aseptic technique and sterile supplies wound care to _____________site cleaned with normal saline in an outward circular motion, pat dry, transparent dressing applied to site with area of wound bed left open, wound bed filled with foam (add black or white and remember to state why and where the white foam is used and the number of pieces used)cut to fit, transparent dressing covered to foam with hole cut for tubing, circle with tubing applied over foam dressing and transparent dressing window pane around area to secure tubing. Tubing attached to vac pac, pressure set at ____ mmhg, patient tolerated wound care waste disposed of properly, and patient is aware that pressure must be kept on consistently. Patient shown that amount of time on vac pack can be found by the nurse at every visit. Patient instructed to keep the machine plugged into the wall whenever patient is at rest to keep the battery charged.

Of course you must always add what the wound looked like, smelled like, tasted like…. okay not that; I was just checking to see if you were paying attention.

Using aseptic technique and sterile supplies shows that you are using correct infection control principles such as the use of personal protective equipment and proper hand washing techniques. Hand washing needs to be taught with every patient but especially where chances of suprainfection are present. Documentation of instruction in the importance and ways to perform hand-washing needs to become an important part of your daily nursing notes. Make sure you use double bagging technique with the use of a small garbage bag for your soiled wound care supplies then tie that bag and place into the patient’s trash container before you leave the home.

Make sure you tell your patient you are going to wash your hands every time you do it and make sure you clean your equipment in front of your patient before you put it away. Make sure you change your gloves frequently and wash your hands before donning a new pair of gloves. Make sure you never reach into your bag without first washing your hands, make sure each section of your nursing bag is zipped after you get your supplies out and when you put your cleaned blood pressure cuff and stethoscope back inside

Writing how you changed a male Foley catheter

Using aseptic technique and sterile supplies the ____fr____ml balloon Foley catheter was changed as follows: procedure explained to patient, supplies gathered, balloon of new Foley tested, ______ml of fluid removed from old catheter and catheter removed without problem, hands washed, new gloves donned, tip of Foley catheter lubricated, cleaning of meatus done using three betadine swabs in an outward circular motion, insertion of ____fr____ml Foley performed without problem, urine return noted, colour of urine noted to be___________new drainage bag hung below level of patients waist, patient tolerated procedure well, waste disposed of properly.

When inserting a coude catheter be sure to document that the red dot at the pigtail was pointed up, this will prove you inserted the coude catheter correctly and caused no harm

First cause no harm is always our nurses creed and the best way to prove that is with your documentation.

I think that the longer you say the instructions, write the instructions and do the instructions the more of a good habit you will develop and your visits will go without a hitch and the better your documentation will become. Not to mention the more informed you will be of all the different disease processes that come your way in home health and the stronger of a med surg nurse you will be over time. All of this will result in the increased quality of care you give your patients which is our number one concern of all. Patients come first in all things and their well being and ability to remain safely in their own home for as long as possible is our goal.

I am sure all of you guys can add your own blurbs to these cheat sheets and it is a great way to make sure that you are teaching as well as writing the same thing every time to all of your patients.

Develop your own note cards or add to these with every new disease process that comes your way. Use the teaching guides in the file cabinet outside Angies office and highlight the parts you taught. MedlinePlus, a part of the National Institute of Health, is a wonderful source of information in laymens terms that you can provide for your patient as well as being able print it off for your nurses notes. If you don’t have a computer then use the library or ask your supervisor for more information if you do not have a teaching guide to use for that process. Of course, it goes without saying that your policies and procedures must state it is allowed to use internet sites and which sites are to be used for patient teaching.

The important thing is the fact that you are instructing and documenting exactly the same thing, you cannot just write instructed on disease process, instructed on diet, instructed on infection control, instructed on med management. You must write it all out on every nurses note or you will not be able to justify your reason for being. Medicare and indeed, all insurances, can audit our work at any time and if the documentation is found lacking, the monies paid to the agency will have to be returned. Worse than that is the liability you take on if your documentation does not support reasonable and necessary care. It would be horrible to be sitting in court room room a year, two or a decade from now with your nurse note shining on an entire wall for all to see. If your note was on that wall would you be able to prove you provided patient care that followed the rules and regulations of the Centers for Medicare and Medicaid Services?

If it wasn’t written...I know you can repeat the next part of that sentence.

Documentation Cheat Sheets

If you are a nurse and needed a quick synopsis of what you taught your patient would this be useful to you?

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Comments 9 comments

lblanton 5 years ago

OMG !! Barbara. Thank you! Thank you !! Where have you been all my life !! This info here is GOLDEN !!


Donna 4 years ago

OMG is right!!! I'm new one month to home health and orientation to what to chart was everybody chart different you'll find your style. Any more help would be great! Thanks again!!!!


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RNMSN 4 years ago from Tucson, Az Author

Hello Donna

you and lblanton made me cry now 6 mo apart :) good things tears are cathartic eh?

I hope your home health orientation will go well and you will love home health!!! Did you find the first part of this series? I hope it helps and I will see what else I can dream up :)....need wound care info? its here as well.

thank you again for making me feel good!

Barbara


Donna 4 years ago

Thanks Barbara I found this site by just looking for help sence I'm not getting it at work. No I didn't find part 1 please help!


RNMSN profile image

RNMSN 4 years ago from Tucson, Az Author

http://hubpages.com/health/Documentation-Basics-fo...

there you go Donna :) all of this was done after the fact for myself and working...

so now you take it and go further...:)

then come back to HubPages and write it out :) now thatd be cool wouldn't it!

Barbara


Donna 4 years ago

Thank you.

do you have any suggestions for verbage on nurses notes Iv been told every note has to start with SN(skilled nurse)assessment completed. and if wd care SN performed wd care, any helpful pharses, thanks again


RNMSN profile image

RNMSN 4 years ago from Tucson, Az Author

good evening Donna! the best thing is always follow the guidelines set by the policy where you work...so if there isn't examples of great charts available then get your supervisor to spell it out


miriamrn 4 years ago

I feel stupid. Sorry to write that but that is how i feel. Can someone please help me with a dc or mod "order" I dont know what is expected A hospital nurse never wrote orders or if she/he did it was coming from a doctor ie, readback order???


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RNMSN 4 years ago from Tucson, Az Author

I apologize but I need more info...I do not understand your question.Take a deep breath :) You cannot just discontinue any order, you know, you have to get all your orders from the MD (or PA or nurse prac) so actually,whatever this problem is...best to take it up with the physician who gave it in the first place.If you cant understand the order,what you need to do is get it clarified right?

so dont feel bad...just get it cleared up...smile and be nice and make sure you get all the parts of that MD order you need to take best care of your patient!

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