Our primary focus for our patients is comfort at the end of life as hospice nurses. We work tirelessly to ensure that our patients receive the best possible care during their end-of-life journey. An aspect of that care that is often overlooked, but incredibly important is timely documentation.
Documenting hospice visits at the bedside is crucial for several reasons. Not only does it help ensure that our patients are receiving the best possible care, but it also helps the hospice team as a whole and reduces issues when the caregiver must be involved in triage services. Here are just a few reasons why documenting hospice visits at the bedside is so important:
It helps the patient
Primarily, documenting hospice visits at the bedside helps the patient. By documenting our assessments and interventions, we are ensuring that the patient is receiving the care they need. It also helps us keep track of any changes in the patient's condition and adjust their care plan accordingly.
It helps the hospice team
Documenting hospice visits at the bedside also helps the entire hospice team. By keeping detailed and accurate records, we can share information with other members of the team, such as the physician or social worker. This can be especially helpful if the patient's care plan needs to be adjusted or if there are any sudden changes in their condition.
It reduces issues when involving triage services
Finally, documenting hospice visits at the bedside can help reduce issues when involving triage services. If a patient's caregiver needs to call the hospice triage line, having detailed documentation can help the triage nurse quickly assess the situation and make informed decisions about the patient's care. It also ensures that there is a clear record of what has been done for the patient so far, which can be helpful if there are any questions or concerns down the line.
Attitude about Documenting in Front of the Patient
One of the biggest barriers to documenting at the bedside is the discomfort some nurses feel about documenting in front of the patient. Nurses may feel that it's intrusive or that it disrupts the conversation with the patient.
However, documenting at the bedside is crucial for ensuring timely and accurate documentation, which is essential for providing quality care. Here are a few tips to overcome this barrier:
Develop one or more templates you can follow so the layout of your narrative is consistent and therefore quicker to type and follow. For example, for routine visits I start off with age, gender, reason for service; then incoming coordination reports (i.e. spouse or 3rd party caregiver reported ______ since last visit), list specific declines you want to call out for others to see or to make it easier to find in the note for when recertification comes along, then the actual physical assessment, then phone calls noting who was called about what including any order/reference id's that another party may need to follow up, followed by teaching to the family closing with narcotic counts.
Pre-document areas that do not require physical assessment in your vehicle prior to going into the home to minimize how much time is spent documenting.
Explain to the patient why you are documenting during the visit and assure them that it is part of the care process.
Position yourself in a way that is non-intrusive and allows you to maintain eye contact with the patient.
Use technology such as a laptop or tablet to document, which can be less obtrusive than traditional pen and paper.
Finally, if you are like me and believe the best way to demonstrate compassion is with minimal technological interference and yet understand the critical value of timely documentation done on site, may I suggest a napkin approach that one might use to pick up something nasty on the floor? I.e. you take a napkin to wrap the item in the napkin, and throw it away… here's how that looks with on-site documentation:
Your entrance to and with the patient and family. There's just you and you put your nursing bag and any technology aside. You embrace (and this can be visual or a handshake or a hug depending on body language et al) the patient and family and soak things in. If this is your first time with the patient and family explain how much you love your job and how you want to keep technology and the mechanical to a minimum. And go over how each visit will involve a hello, how are you doing, how have you been, etc. Then a physical assessment, then the documentation before closing remarks and follow up free of technology and mechanics.
Have your opening discussions taking notes for which I recommend using a clipboard.
Do your physical assessment taking careful notes again considering a clip board.
Then sit nearby and chart the visit on your tablet/laptop doing your best to have frequent eye contact with the patient and family. As you get close to the point of the documentation where you would make phone calls, explain you are now going to call in new orders, refills, etc. and let the patient and family hear your calls and conversations as it does reassure them and build trust with them that you are thorough and meeting their needs. Document those calls including who you talked to and expected outcomes such as delivery tomorrow or an order id along with any type of follow up needed.
Document your education that you will shortly provide and use the education discussion to separate you from the technology.
Tips for documenting hospice visits at the bedside
Now that we've established why documenting hospice visits at the bedside is so important, let's talk about some tips for doing it effectively.
Document during the visit itself: One of the most important things you can do is to document during the visit itself. This ensures that all your assessments and interventions are fresh in your mind and that you don't forget anything important.
Be thorough and detailed: When documenting, it's important to be as thorough and detailed as possible. Include all relevant information, such as the patient's vital signs, any symptoms they are experiencing, and any interventions you have performed. Make sure you are documenting declines that will be noted or otherwise help on recertification.
Use clear and concise language: It's also important to use clear and concise language when documenting. Avoid using medical jargon or abbreviations that may be difficult for others to understand.
Record all telephone calls made, the reason for the call, to whom you spoke, any order or reference id numbers and details that may help another person to follow up on the results of the call(s).
Double-check your documentation: Finally, be sure to double-check your documentation before leaving the patient's room. Make sure that everything is accurate and complete, and that you have documented everything you need to.
Conclusion
In conclusion, documenting hospice visits at the bedside is a crucial aspect of hospice care. By keeping detailed and accurate records, we can provide the best possible care for our patients, help the hospice team, and reduce issues when involving triage services. By following these tips for effective documentation, we can ensure that our patients are receiving the best possible care during their end-of-life journey.
