Why did I make this website?
I have been working in the home health industry for the last 7 years. During this period, I worked for Medicare-based agencies and agencies that accept only private insurance. 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 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.
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 assessments 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, assessments 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 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 documentation, 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.
How to use this site?
All the selections you make by clicking on the individual sections along the entire assessment can be submitted to generate the summary, by clicking on 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 documentation quicker and easier.
Another deficiency I encounter with documentation is in the section on patient teachings and instructions, especially medication teachings. I wanted to offer some assistance to my fellow nurses on the same, by offering some patient teachings, which could be copied and pasted as well. In total, I provided about 1,700 patient teachings, with many more on their way.
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 will be working on the site improvement, adding templates for various other health conditions and more patient teachings. Please feel free to write to me regarding any health conditions you need templates and teachings developed on. I would be more than willing to contribute towards my commitment to better documentation.