I keep the bedside documentation to under 15 minutes (admission visits not included) by creating muscle memory by following consistent templates based on the type of visit (routine, PRN, recertification, death, and admission).
I've previously shared my recertification template, so let me share my routine visit template for today. For those new, routine visits are scheduled ahead of time, and while you may arrive to find a crisis before you, the visit itself was scheduled and therefore considered routine. It is regarded as part of the four hospice care levels according to Medicare guidelines.
The template for routine visits is broken down into sections where I use a paragraph for each section:
Age Gender “on service for” Primary DX. For example, a 92-year-old female on service for Alzheimer's.
Coordination notes for any status reports received before arrival, which could be noted from triage, CNAs, MSWs, etc.
Coordination notes from the onsite caregiver, family member, or primary nurse if at a facility. Take careful note that best practice for Medicare involves the parties showing and providing evidence coordination between all parties is taking place; remember the old saying, “If it wasn't documented, it was never done.”
At least weekly, a list of declines by line item (each decline on its line) that have occurred in the last one to no more than two weeks.
The physical assessment notes that I do my best to use negative language, such as disoriented x3 vs. oriented to self only.
Telephone calls include the person on the other end, the company/organization, why the call was made, and the expected outcome. This can be as simple as writing “telephone call to John Doe at XYZ pharmacy to refill duonebs for Saturday delivery on request of the family” or as detailed as a specific type of x-ray to rule out ________ with reference # or order ID #. Each call is on its line.
Education provided to _____ on the disease process and progression, including any specific areas you called out that might involve a PRN visit by another party. For example, I have a patient with a history of seizures where one family member is highly concerned about the diazepam rectal syringes to deliver the 12.5 mg of diazepam. Therefore, every time I re-educate and reinforce the medication use, I am particular that it was taught/reviewed. Remember, if it was not documented, it was not done, and the last thing you need is to have a family member state they were never told/educated, especially if it is something critical.
If the visit was for a facility patient, document who you updated after the visit as part of post-coordination, along with any key areas such as complaints of pain, nausea, vomiting, intractable cough, etc.
Narcotic counts for home patients.
In my experience, if you find a template (it doesn't have to be mine above) and use it consistently, you are less likely to miss things and be encouraged to document within the visit itself.
I recommend learning to touch type, and consistent methods of what you document will lead to reasonable documentation times without burning you out.
