Documentation


DOCUMENTATION EXAMPLES

© 2009-present by Kathy Quan RN BSN -- ALL RIGHTS RESERVED 

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!

Documentation in home health care is cumbersome, sometimes confusing and can be overwjelming if you let it. 

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 even have to complete your documentation in the home so you can obtain signatures from patients or caregivers. 

This is good, but can have some drawbacks. Be sure to focus on the patent for the visit and then explain you need to take a few minutes to document everything before you leave the home. Encourage them to think about what was discussed and taught and see if they have any more questions before you leave.  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:

Documentation Tips (from HouseCalls-online.com)

Sample Documentation 

Why Do I Have to Document? 

Diagnosis Related Homebound Statements

As an individual, you may use some of the phrases, or change them to fit your own cases, 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. 

However, if you wish to use these lists for staff or physician education, or other purpose, please email me for directions. 

For further help with documentation, check out my online course at kathy-quan.Teachable.com  
(The price has been reduced to $99)

No portion of this documentation can be used without written permission. EMAIL me for permission to use. 

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