Sample Documentation

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The Case Description:
Carolyn is a 40-year-old female who works part time in a medical office. She has some mental health issues that have not been fully diagnosed. Behavior issues have plagued her for years and her family helps support her so she can live on her own.  She was recently connected with a mental health clinic in her hometown and will follow through with assessments and treatments.

Meanwhile, she passed out at work one day after skipping lunch so she could leave early. (She takes 3 busses to get to work, and the bus drivers were going out on strike later that day so she wanted to get home before she couldn't get there.) One of the physicians in her office noted Carolyn's symptoms and checked her blood sugar quickly. It was over 500. He had her admitted to the hospital next door for some tests and diagnosed her with DM II initially requiring insulin to control the blood sugars which were bouncing all over.

Three days later Carolyn was released and the MD ordered a home health nurse to make daily visits to assess and provide new diabetic education. He will sign the 485 and manage the home health POC. Carolyn has private PPO health insurance that her family pays for. There is no prior authorization needed but she has a limit of 10 home health visits for this year. MSW is not covered but has agreed to consult by phone if needed.

Carolyn was prescribed metformin 500mg BID and Lantus 10 units sq at HS. She has a long recorded history of failing to take medications on a daily basis. She takes PRN meds ok when she recognizes symptoms. She may need to take regular insulin if her blood sugars aren’t controlled by the meds. 

With only 3 visits allowed by her insurance, the SN needs to make good use of the visits and hope the patient can retain the teachings. She needs to make sure a reliable family member is there to inst. as well.

On the first visit, Suzanne the RN gave Carolyn lots of literature to read hoping she could use this method to instruct her, have her re-read, and then have the materials as backup. But she soon discovered Carolyn has difficulty retaining what she reads and since she doesn’t know what she doesn’t know, it will be impossible for her to just read the instructions. 

Jane, Carolyn’s mother is present for the first visit and seems very ready to learn. Jane switches gears and brings up a You Tube video on blood glucose testing. Thankfully it’s the exact glucometer that Carolyn has. Jane and Carolyn watch the video and follow along step-by-step. Suzanne only prompted them as absolutely necessary. The random blood sugar today was 196. Carolyn ate at 5:30 AM before the nurse arrived at 7:45 AM even though Suzanne had told her not to eat before she got there. 

Suzanne bookmarked this video on Carolyn’s laptop so they could review it again later when she takes her blood sugar before meals and at bedtime to try to establish a pattern and see the effectiveness of the medications.

Thankfully, the dietitian in the hospital had been able to make good headway with diet instruction and Jane has good knowledge about sugars in foods. Carolyn had not taken her Lantus last night even though she was given a prefilled syringe and had demonstrated self injection in the hospital. That helps explain the higher BS this morning.

Suzanne brought a med box and calendar to profile with the metformin and vitamins Carolyn takes as she remembers. She demonstrated using a calendar to remind her and to cross off when she had taken her meds. 

Lastly, Suzanne had Carolyn demonstrate self injection using sterile saline instead of the Lantus. Together they prefilled 3 syringes for the evening doses.

Tomorrow they will review and move forward with the diabetic teaching. Suzanne will assess for compliance, understanding and effects of medications if follow-through is there. Jane agrees to check in with her daughter at regular intervals to promote blood glucose testing and medication compliance. She will also discuss any s/sx of hypo/hyperglycemia and treatment. Jane has purchase foods to follow the meal planning the dietitian gave them. And she has removed the high sugar content foods from the home.

How do you document your assessment and intervention?
No matter what type of charting your facility uses from checklists to full narrative discussions, you need to be sure to include the most important details. To tell the complete story accurately, you need to include "the 5 w's and an h." These are the Who, What, When, Where, Why and How.

There may be more than one way to answer or interpret these questions, but let's examine one way.

The Who: of course is the patient, but if the problem related to your documentation is, for example, about family discord, the who could be the family or a specific family member. 

The What: is the focus need; Diabetic teaching complicated by learning issues. Pt. ate breakfast before testing glucose despite request from RN. The HOMEBOUND status would involve unsteady blood sugar levels that may cause patient to have confusion or even to lose consciousness as she did at work.  [Obviously this won’t keep her homebound very long. Her private insurance doesn’t require her to be homebound. The goal is for her to attend classes and seek outside education about her diabetes after a few SN visits.]

The When: teaching began upon the arrival of the SN today and will continue for 2-3 more daily visits

The Where: Carolyn’s home in the kitchen

The Why:  Carolyn is a newly diagnosed diabetic patient who needs more education about her disease, treatments, s/sx of complications.

The How: The interventions: the video about the blood glucose, bookmarking the site for their future reference, the actual testing and result. The education about when to test and s/sx of complications. They prefilled syringes and Carolyn demonstrated good technique with self injection of 0.25ml of sterile saline. 

Whatever the format for your documentation, if you can make simple notes for yourself as to the who, what, when, where, why and how and make sure that you have included all of this information in your charting then you will have accurately and adequately documented the episode.

Your documentation must be factual
  • Use quotes from the patient or caregiver.
  • Remember, you're not writing a novel. 
  • You don't need to fret about making it all sound good and have a strong story line. 
  • Just give the facts. 
  • Don't interject your opinions. 

TIP: Use patient statements to define subjective aspects. With a blood glucose of 196 you might expect some symptoms of hyperglycemia. Ask open ended questions to elicit information and quote the patient. 
Or if your patient says his pain is 10/10, describe his behavior to justify or perhaps even question his tolerance level. 
NEXT Ten Tips for Effective Documentation
Why do I have to document?!

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