Home care is all about efficiency, whether in regard to providing optimal patient care, in seeing the most patients in the day safely, or in completing the necessary documentation for each visit.
This month we will discuss the best ways to effectively complete the needed paperwork for each client so that you don't have to do it after hours.
Depending on the agency that you work for, you may document electronically, via laptop technology, or on paper forms. We'll start with paper forms, as this can be easier for some to master.
When I used to have to complete my documentation on paper forms, I would start the general information the night before or early in the morning of the visits. This basic information can include the patient name and identification numbers, reasons for visit, plans for visit, and if it was a known patient with chronic wound care, I could even start that documentation.
This would allow me to reduce the time spent in the patients' home writing notes, as the majority of the form would already be started. Information that would be done during the actual visit would include vital signs, any measurements (wound size, drainage, blood glucose, etc.), and patients response to treatments.
If this was a known patient, I could begin to write what type of teaching I had planned for the visit so that I didn't have to complete that in the home. However, this could backfire if the patient developed a new problem that needed more immediate instructions or care. If this happened, I would have to destroy that semi-prewritten note and start fresh.
Again, I want to stress, that I did this type of 'pre-writing' only on clients that I had a pretty good feel for what I was going to do on that particular visit. Most often, on the long term wound care clients. With electronic documentation, this can be completed only in particular instances.
In my agency, I cannot create a note for a patient until the given day care is provided. However, I have extra time in the morning between dropping off my children at their bus stops, so I have the ability to "attach" the notes for each patient visit for the day. This allows for me to go directly into the patient note in the client's home, so that documentation is quicker and easier.
No patient has ever complained about me using my computer during my visit. I take it out of my bag, first thing, while asking the client how they are feeling, if there are any problems or concerns. After unlocking the computer and entering the patient note for the day, I can prepare for my assessment of their condition and for any other treatments that may be needed.
By having my computer on and close by, I can quickly enter the vital signs and any other pertinent data for the day. Also, some quick notes about any instructions done that day or if there are any alterations in status, medications or treatment plans. By getting this information in quickly, I am sure I will not forget anything.
After providing whatever care is needed for the visit, I will usually sit and talk to the patient while I have the computer on my lap, and I can discreetly type in additional information. With this method, the majority of my note is completed in the home, ensuring that I did not forget something, and I will only have to review and add a little more information after getting home.
The key to time-efficient documentation is getting a flow of what you will need to include in each note and, most importantly, completing point-of-care documentation. Doing most of your documentation in the patient's home allows for the most complete note that truly encompasses what was seen, heard, and done for the visit.
Linda Snyder is a wound care nurse at Keystone Home Health Services in Wyndmoor, PA. She is currently completing her MSN through Walden University.