Tips for Hospice Nurses: how to structure your documentation / nurse’s note.

Описание: Tip for #hospicenurses:
I had a question about how long the #Hospice #Narraitve Note should be. There’s not one clear answer, so in this video I’m talking about how I structure the note on a very routine visit with no new issues, no needs or concerns. On these very routine visits, I always follow the same 4 section format.

Sec 1: the Header paragraph that gives demographic info on the pt, their primary diagnosis, secondary complications and comorbid conditions. Generally this paragraph is always the same, so I #copyandpaste it to save time. (See prior videos for #tips on how to #document the header)

Sec 2: I discuss where the pt was and what they looked like when I walked in. Then I will document diagnosis specific findings to support eligibility.

Sec 3: This is where I address #pain and #nutrition because we have to document on these areas every visit. (I’ve done several videos on how to document “normal” findings in these areas that will support eligibility).

Sec 4: the Closing Paragraph is generally the same. This is where I document pt/Cg agreement with the hospice #PlanOfCare, revisions to the #POC, and medications or supplies that were ordered.

You can find examples of how to document each of the sections in the “Hospice Nurse’s Guide to Documentation” and the “Supplemental Guide to Hospice Documentation” - both available on my website: www.AmityStaffing.com/products

#tipsforhospicenurses #forhospicenurses #documentation #hospicedocumentation #amitystaffing #documentationguides #guides #hospicebooks