This article is intended to help new visiting hospice nurses who are struggling to maintain work-life balance who may have been told by others their visits are either too long or being questioned why they are taking work home with them. This article will deal strictly with home patients though the bulk of the tips will apply to almost any type of patient or visit.
Even though there is no such thing as a typical visit for a terminally ill patient in terms of what to expect in advance of arrival, if you follow the guidelines presented in this article you may find yourself becoming better at documenting within the visit and taking zero work home with you.
A. Start a recertification journal (paper or electronic) where you keep track of start of care (SOC) dates, height, weight, BMI, RMUAC, KPS/PPS scale, FAST scale as appropriate. In this journal, you will add recert dates along with the appropriate scales and keep track of declines in between the SOC date and the first recert, and then from the last recert to the next. This journal will help you gauge continued eligibility, and help you know your patients better such that your visits can be more focused.
B. Start the actual visit in your EMR just before going into the patient's house. Then do what I refer to as pre-charting where you will go through each area that you know the answers (i.e. if the patient is always incontinent of bladder, then check that area if your software asks for it). Leave those areas unchecked/un-assessed that you need to assess in person with the patient. For Home Care Home Base (Point Care), this means complete all interventions (that you will do in the visit, but can document in advance), the mileage and time, and you should be able to check off at least 75% to 80% of the other check boxes in the physical assessment.
C. Now enter the patient's home, introduce yourself if this is your first time there (I always share I'm a visiting nurse vs a visiting hospice nurse unless I am 100% sure the patient is on board and will not be in distress even though our uniform and bag have the word hospice on them). All this time and through your visit, you should be observing the patient (complexion, ability to track your movements with their eyes, body language, visible contractures if there are any, and so on), and watching the interaction between the patient, family, and caregivers (as this can give you clues as to how to best interact with everyone).
For the first visit, I recommend getting to know the key players who are involved in the patient's lives, keeping in mind the time. Name, relationship, and if a third-party caregiver, then how long have they been caring for the patient. For first visits I also recommend asking why they came onboard (either mentioning hospice directly if appropriate or keeping it simple and using other terminology that is acceptable to all parties). Since every single visit should involve assessing whether a patient has two weeks of life left, personally I love hearing the background story as velocity of changes of condition strongly indicates how much time a person has to live when they are in a terminal state. Keep in mind that in addition to assessing for EOL (two weeks or less) status on every visit, each visit should also include education with the goal to prepare the patient, family and caregivers for a good death.
In terms of the structure of each visit:
Conversation about how the patient is doing from the last visit as part of the interviewing and observation. Do your best to keep everyone focused and if there are new symptoms use the nursing prioritization process to focus on the one symptom creating the most dismay for the patient.
Perform a focused assessment that considers the primary symptom that is causing distress. I cannot stress enough this is where a lot of time can be misused. You do not need to do a full head-to-toe assessment each visit. If the patient is reporting regular bowel movements without any complaints involving the GI system, you do not need to listen to bowel sounds every visit! We should be listening to lung sounds, obtaining an apical heart rate when able (muffled heart sounds can make this a challenge, then go with radial or pulse ox), respiration count (where it is vital to count for a full minute if you believe there's a change of condition), blood pressure, and most systems want a temperature. Write down the values on an assessment sheet you can leave with the family after you are done transferring the values to your electronic charting system.
Perform any functional tasks such as wound care, Foley irrigation, etc.
Now, find the best place in the environment to chart the vitals, your assessment, and the narrative. It's this time to reinforce education, check what refills are needed, call the pharmacy, and make any other phone calls needed. Document each call noting whom you talked to in relation to what area.
Then provide the various parties with any reminders, final reinforcing remarks, get a signature if needed and that particular visit is done.
Remember “A” above with the recertification journal? Keep track of when the next recertification is done, and spend some quiet time drafting the meat of the recert note using declines you've tracked and then copy and paste that draft into the narrative of the appropriate recert visit and you'll find recert notes take less time as you will have most of it done without spending time within the visit where you can be drawn into areas unrelated to the tasks at hand.
Those of you who can put into practice the above methodology will take zero to close to zero work home each week. When you have IDG notes, the recertification journal you are keeping up to date will drive those IDG notes which in turn result in less time spent on IDG notes, and they will drive your recertification visits making those visits take less time as well.
