Be afraid. Be very afraid of a nurse who loves to document. If you are a nurse who loves to document, please navigate safely to another website and never, ever come back here. For the rest of you, here are five tips that will shorten the time you spend documenting, increase the chance that your agency will be paid and keep you out of regulatory hot water.
- Don’t be redundant. Do you like talking to people who repeat themselves? Do not elaborate on ordinary information that is part of the flow sheet component of your visit note. Example: Pt awake, alert and oriented for visit. Denies pain.(Assuming you already checked the boxes for neuro status and pain on the flow sheet.)
- Step away from the computer when writing care plans. The care plan should address the diagnoses, medications, out of range parameters and teaching. And not much else. Care plans cluttered with orders to address ‘just in case’ situations are useless. Example: A patient with no cardiac history is admitted for diabetic teaching and has, ‘teach signs and symptoms of an impending MI’ on the care plan. Why not reserve that order for people who have heart disease?
- If you attach a teaching guide to your notes or upload one into the computer, documentation can be complete by simply stating that teaching was offered according to sections A and B of attached Diabetic Care Plan. (Name the care plan and include the source – ADA, NIH, etc.)
- Pasting teaching material into electronic documentation does not save time. Every sentence must be read and considered in light of your patient. If it is not reviewed, you will end up with documentation that reads something like, ‘Taught patient to avoid contact sports while taking medication’. If a patient can play contact sports, they might not be homebound. There are also visit notes that include teaching for men to notify their physicians should they become pregnant. This would be very difficult to argue in an appeal.
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Documenting everything the patient denied is not useful. In fact, it paints a picture of a patient who might not need services. If your patient denies falls, shortness of breath, chest pain and difficulty with urination, ask yourself how important that information is to your individual patient. The denial of falls would be important to patients admitted for therapy because of a history of falls. It may not be relevant to a patient that is chairbound admitted for diabetes.
Cutting down on the clutter leaves clean documentation where it is easy to find the information needed to determine payment. It takes much less time to document leaving you with more time which can feel like a luxury on some days.