Documentation and paperwork is a huge part of nursing, and this is especially true in home health care. Get used to it. The more you fight it, the harder your job becomes!
Be organized, and get the paperwork done as soon as your visit is complete. That way the information is freshest in your mind and by doing so, you relieve yourself of the burden of doing it later! With laptops you may have to complete your documentation in the home which is good, but can have some drawbacks. Double check what you have done as soon as you get to your car.
Here are some samples for hints and to show why documentation is necessary:
Sample Documentation (from TheNursingSite.com)
Diagnosis Related Homebound Statements
Use some of the phrases from the Homebound Statements list to reinforce this status. Many of these statements can also serve to help justify the medical necessity or skilled need.
© 2009-present by Kathy Quan RN BSN -- ALL RIGHTS RESERVED
No portion of this documentation can be used without written permission. EMAIL me for permission to use.