Quick and Quality Home Health Nursing Documentation
Greetings from Home Health Patient Education! I am Jay. I am RN working in the home health industry for the last 10 years. I created Home Health Patient Education with a vision of assisting field nurses create quick and quality home health nursing documentation. Creating good quality nursing documentation in home health industry can be very time consuming and nurses complete the paperwork at home, taking time out of personal life.
I have worked for both Medicare-based agencies and agencies that accept only private insurance. Based on my observation, home health nursing documentation for private insurance patients is easier and less time-consuming, owing to the fact that answering the long OASIS document is not a requirement. Also, in comparison to someone in the Medicare age group, these patients have fewer health complaints due to the younger age group they are in, which means lesser documentation time. I always felt nursing documentation for a Medicare patient would never be complete and kept checking on my notes time and again, just to be sure that I am not leaving any gaps. Obviously, this takes time, failing to do so compromises the quality of the document and good quality nursing assessment notes is need of the hour.
Whether one hand-writes or uses EMR software for documentation, one deficiency I frequently come across, is with the comments section on the individual pages of the OASIS form. While doing the QA on the skilled nursing assessment notes turned in, on many occasions, I find the comments section blank. Upon asking the visiting nursing staff the reasoning behind not making any comments, I was told that they checked some boxes on the OASIS form and wondered if that would not suffice. I hate to say this, but my humble answer for this is “no”.
Now, let me explain why that would not suffice with the help of 2 illustrations below.
- Illustration 1: If a patient is positive for congestive heart failure, though checking the box for CHF on the cardiovascular section of the assessment and marking for edema on the day of visit is important, these mere selections would not provide any information regarding the management of the condition. There are other aspects that need a mention, to complement the selection made for CHF. This includes information regarding the patient’s presentation of symptoms in recent times, such as, exacerbation of pedal edema, any evidence of fluid back up in the chest, any exacerbation of SOB lately, changes in the diuretic dose, potassium supplementation, episodes of hypotension in recent times, any dizzy episodes, recommendation for fluid limitations, compliance with the dietary recommendations, and any changes with endurance levels lately.
- Illustration 2: If a patient is positive for Chronic Obstructive Pulmonary Disease, just checking the box and making selection of COPD on the respiratory section of the assessment would not give a complete picture regarding the management of the condition. Adding comments regarding aspects such as, compliance/noncompliance with smoking cessation (if the patient was a smoker), varying abnormal breath sounds, knowledge regarding and compliance with pursed-lip breathing, recent changes with the patient’s lung volumes, any changes in the dose of inhalation medications, any consistent deterioration in oxygen saturation lately, any recent chest infections, and any signs and symptoms of worsening pulmonary hypertension would provide more insight, as to whether the patient’s condition is progressing or deteriorating.
Adding these comments not only provides valuable information regarding the patient’s health but also adds more justification for the admission/recertification to home health. Without these comments, home health nursing documentation with just check marks on the boxes for various health conditions would make no difference from one certification period to the next. These comments translate into defining your goals better and thereby, provide new guidelines for patient instructions and teachings. Good home health nursing documentation will also offer an easy and better reference with regards to the patient’s health, thus reducing the learning curve to any new visiting nursing staff, if the staff visiting the patient were to change, a situation that we frequently encounter in this industry. Also, as the progress patients make on their goals is a direct measure of your performance as a clinician, these comments made over a period of time, offer you the credit you deserve for the efforts made.
I admit that adding these comments will take unduly long time, something that is difficult to manage. I used to struggle a lot adjusting this time, in order to make the documentation look better. I always felt the availability of some pre-made templates would help saving the time for skilled nursing assessment notes, yet retaining the quality of the document. So, I took up the task of making these templates and tried to organize these health conditions and contents on the site, in a way where you hardly have the need to handwrite or type any information, but generate your comments by making some selections.
We offers two products as a solution to create faster home health nursing documentation:
Dynamic Nursing OASIS Assessment templates
Our Skilled Nursing Assessment templates generate customized narratives for individual patient needs with few clicks. The narrative is generated once you click the Submit button at the end of the page. This summary could be copied and pasted into the comments section, if you use an EMR software, or copied and pasted onto an addendum sheet that you can attach to the OASIS form if you use paper documentation. This helps in making the home health nursing documentation quicker and easier.
I have saved up to 15 to 20 minutes per assessment using these nursing OASIS assessment templates. If you consider doing at least 2 assessments a day, you are saving at least 30 minutes time from writing notes.
To help you understand better what I am talking here, I am providing a demo skilled nursing discharge assessment template where you can generate discharge summary using selection options provided. Please visit OASIS Discharge Template
I offer skilled nursing OASIS assessment templates for – start of care, resumption of care, recertification, 60 day summary and discharge.
Another deficiency I encounter with documentation is in the section on patient teachings and instructions, especially medication teachings. As a home healthcare nurse, we need to educate our patients regarding their current health status and how to manage to improve it, provide them with tools which will help them meet the goals defined on their plan of care. I noticed patient teachings material for home health industry was not available in the format we usually teach or write on skilled notes. I wanted to offer some assistance to my fellow nurses on the same, by offering some patient teachings, which could be copied and pasted onto their nursing documentation. The nurses can use these patient teachings to educate their home bound patients as well. I offer nurse teachings based on different systems and commonly used medications and medication groups which can be easily incorporated into the notes. Currently we offer more than 6000 patient teachings!
With patient teachings covering most of the common ailments for home health patients, you can teach the patients about their health easily thus improving patient satisfaction.
I hope you will find this site in good standing with regards to what I promised to offer and also, as a good educational tool on the front of patient education. I also hope it offers my colleagues working in the industry a quicker way to complete home health nursing documentation. I will be working on the site improvement, adding skilled nursing OASIS templates for various other health conditions and more nurse teachings. Please feel free to write to me regarding any health conditions you need templates and nurse teachings developed on. I would be more than willing to contribute towards my commitment to better nursing assessment notes and documentation.