Documentation Fundamentals for Home Health Part II

Maybe they are not familiar with what to write!

As scared as I was during the days of having to apologize to my work as a final point, it became clear to me that perhaps were not ruffled feathers BEC. I'm new and they are not used to control, can spout. They do not know very sincere medical surgical nurse and his big mouth to cover their ignorance!

The passionate looks, I know, but lets face it, I was there on one occasion.

I know how I was scared when I can not tell how a person celiac instruction! I do not mean a celiac patient care, rather than! I had to look up! I did the last I went to my patient, of course, but that is usually the first instruction to read the newspaper I had copied!

After that, I knew I repaired to learn and I can do something better if I knew what I did or that the patient would probably call my boss and say, "Where did you get what Yahoo and take it and send me a real nurse? "

Because in the south, which would essentially be that you can be!

So I wrote a cheat sheet for unusual disease process, not much, just to see if the staff will take and basically copy their notes! Tell me what you think.

An example

Cheat sheets for more information

Of course, using our guide of ideas is much easier than that, but

At first, I mean, we are grateful for all your hard work and excellent, we just want to make sure all bases are covered and that your documentation because of the quality of care you provide and support the need specialized care.

The nursing note indicating that no doubt your label format, write on each line, print if your handwriting is understandable, using a communication NOTE: If you do not fit the format. You can not write a sequence of events that covers the failure and go to guide and promote the objectives of w / n the back of the ticket itself. You must determine the disposition of nurses note, or we are out of compliance w / our own procedure.

Here are some basic cheats in our process of the disease the most common. I'm sure you can add this to your own note cards of the operation was a great way for me to get any information from disparate pathological processes of learning. In my opinion, I thought it was a huge deal if we as an end point was the teaching guides, saved my hands as a writer's cramp, without hesitation! In contrast, if you do not use the guides you need to write exactly what you said that your patient then here are some for your use.


Lung disease of chronic bronchitis and emphysema. It causes the cells at the tips of tree branches in your lungs approaches to address and facilitate breathing. Increased mucus cough w / is one of the first signs of COPD. Smoking is the most common cause of COPD, while smoking cessation is the most important thing you can do. Drug treatments using oxygen and respiratory tract will make you more comfortable.

Another important thing to keep in mind is the infection under control. People w / COPD are more susceptible to infection to prevent people w / respiratory, and positive for washing hands thoroughly and regularly for 20 seconds with warm soapy water. Hand washing is the most solitary οf prevent infection spread. Wash your hands before and after using the toilet tο before and after eating, before and after medication, and after coughing up phlegm. Have tissue in the trash immediately.

Get your pneumovac as agreed, usually every five years and get your vaccine against influenza annually.

Signs of complications οf οf οf COPD report includes changing the color or mucus οf constant. Mucus COPD is remarkably white and fluffy. Shortness of breath οf increased comfort w / οf use inhalers or take a break. Increase in temperature, chest pain and fatigue can often be signs of a lung infection.

Good use tο nebulizer

Nebulizer treatments are often used in COPD lung infections or other in a small, but the source, such as pneumonia. However, whether or not wrong would not be effective and the drug would not be able to work and you feel more support. Nebulizer machines use soft power to support the medicinal products in your lungs, you need more work. Sitting at a time, tightly holding the mouthpiece in your mouth and breathe deeply, and keep the medicine into your lungs. You should never puff of medication and quick to smoke a pipe. Breathe deeply into your lungs as deeply as you can and hold it as long as you can be too late to be routine and repeat until the medication has completely evaporated from the cup.

Another key element to keep in mind w / the fight against infection. Each part of the nebuliser should be disassembled after each use, clean with hot soapy water, rinsed with clean water and paper towels to dry the air to set. In the barren, save documents in a zip lock bag until next time.

Properly use inhalers

Spiriva is a powder that comes in the form of a capsule. There is a special box that when you turn it will open four small pins that will pierce the capsule to release the show powder. Place the dish in the back room and turn the container to the critical position. Keep the room with determination in the middle of your lips, press the buttons on the side, and breathe deeply. Special button. The pins will pierce the capsule and the blue side buttons are pushed. Turn the piece and breathe with your head back again. You can enjoy a sweet taste and hear a buzz. The parts of the powder in your mouth, it would not hurt you, but this may be due to press the button more than once. If the capsule is empty at the end, take it out and put in the trash. Sometimes it takes more than twice the empty capsule.

Whether you are a metered aerosol, the main thing to remember is to keep your room at a 90 degree angle to your face, mouth slightly to keep the middle of your lips and exhale as you compress the spray. Keep the medicine into your lungs as long and deep as you can blow wise and wait at least three minutes before the second puff. Many inhalers containing a steroid and it is essential that you rinse your mouth after use for sores in the mouth to avoid.

Nutrition for people with COPD

People with COPD have little breathing easy while trying to eat. At the same authority, is trying to breathe them to lose calories at a rate more directly. It is important to eat small meals between intensively with calories. This will help keep your skin fresh and so out of breath just trying to eat a meal spectacular, three times a day.


People with hypertension have a reduced heart stage of normal physiological function. It is caused when the heart is incapable of movement of the body's blood qualified due to the increased pressure on the vessels. The top number, systolic blood pressure shows what your heart as you move and energy costs. The bottom number, diastolic, indicates the pressure in your heart at rest. That's why nurses are particularly concerned when the lower number is high or too close to the higher number. This means that your heart is under a lot of pressure just trying to keep the blood from one place to another in your body. Hypertension, left untreated, can lead to heart attacks and strokes.

Signs to account for nosebleeds, severe headaches and blurred imagination.

Ways to prevent complications include eating a well balanced meal with lots of fresh fruits and vegetables, to refrain from the use of salt as the use of salt substitutes in potassium, the use of herbs in food and exercise can induce. Refrain from red meat, fried food to refrain from, refrain from processed foods and junk food, grilling or frying meat and add the chicken and fish to your diet in limited quantities. Whether you use canned vegetables, you pour the liquid from the can and replaced by water, to refrain from frozen as they are preserved with salt and contain more salt than canned foods. Walking is the best exercise and help maintain a healthy weight a little, which in turn will lower your blood pressure.

Take the medication as prescribed by your doctor ordered and maintain a written record of your blood pressure is also helping to boost your treatment. Blood pressure and also wrote regular if all your medications with you to each doctor visit.


Chronic heart failure is a form of reduction in the heart of a normal physiological function in which fluids build around the heart and the heart is unable to pump vigorously pump and from the lower elements of your body. Your heart is very selfish, it makes for itself and its surroundings. But once the blood and fluid to work your legs and heart of the toes would not be out of his way back to your lungs. This is why your legs and feet swell especially if you are or not in need of care throughout the day. Elevation of the legs at rest is more important than walking. The pumping action created by walking with your blood and fluid into the trunk where it can propagate back through the lungs and heart.

Including ways to manage avoiding salt, the height of the legs at rest, a medication orders of physicians and exercise as a state, sleep with your head above your heart. The optimal use of the Readers Digest condensed books as gag p your bed on top, so you can pose no difficulty breathing at night!

Signs of complications to report waking in the middle of the night unable to breathe. Frequent urination at night is a sure sign that you should see a doctor quickly. Weight gain of 3-5 pounds in a day or a week means that you must see a doctor. Breathing increased complexity, changes in color or consistency of the mucosa and increased cough.

Weeping liquid legs often includes people with CHF due to the fact that the liquid is not possible to return to the upper body and he will come through the pores of sin. Untreated, can lead to cellulitis, an infection of the deepest layer of the skin, open wounds and systemic infections. It is essential to help prevent increases in the legs at rest, keep the skin clean and dry as possible, refrain from scratching or hitting your legs and see your doctor to lower the sign of the fluid of your cry legs. Prevention of secondary infection is required for hand washing is essential. Hand washing is the most important to prevent the spread of infection. Wash your hands often and thoroughly for 20 seconds with soap and water. Wash your hands before and after using the bathroom, food and medicine.


The skin consists of dermis, epidermis and subcutaneous layers. When infection occurs in these layers causes a red, sometimes itchy, painful infection called cellulitis hot. It can lead to a high temperature, chills and muscle aches. The red area grows and spreads quickly, and untreated can lead to systemic infection, which means it can spread in your blood.

Cellulitis is treated with antibiotics by mouth, sometimes, and sometimes even as a local wound after open areas are needed. The most essential thing to do is get your hands and the infected area as clean as possible. Hand washing is the most critical to the spread of infection. Wash your hands often and thoroughly for 20 seconds with soap and water. Wash your hands before and after using the bathroom, food and medicine.

Signs of complications include worsening of cellulite, such as open wounds, changing the color of drainage, presence or absence, increased pain, warmth, redness or discharge of a larger body part. Cellulite is most often the feet and legs.

Cellulitis is a bacterial infection usually caused by Staphylococcus. These and all the bacteria on and around us all the time. When bacteria are causing problems when it is in our bodies, such as a cut or break in the skin. Cellulite, usually bet back injury as a cut or scratch.


CABG surgery is performed when the blockages in the heart and lead to chest pain or heart attack. A boat comes from the leg and used the artery with the blockage of your coronary artery bypass surgery. You will check on your leg or both legs depending on how surrounding roads and asked to see the area heals without infection. Sometimes the area just above the knee or just below the knee is opened and cry and may need to be dressed on a daily basis and kept clean and dry with soap and water and the open or there is no drainage. Immediately contact your doctor or nurse or open areas on your legs, crying, swelling, pain, or have any type of drainage. You will also be two or three areas on the belly, where the drains were placed and often those under your breasts, the longest to heal because they were wide and deep. Also monitor these areas and ensure they are not around redness, heat or pain, the area in the center of the chest will feature less time to heal and can cause itching, but do not come look at her or scratch or any of the fields. Prevention of infection is essential. Hand washing is the most necessary for spread of infection. Wash your hands often and thoroughly for 20 seconds with soap and water. Wash your hands before and after using the bathroom, food and medicine.

The most essential part of the rebirth is your mentality. You have a brand new plumbing system for your heart, but whether or not your lifestyle to fit you right back where you started it did not last long. Nutrition is the main thing that needs to adapt. Decrease in the amount of red meat, eat chicken and fish, grilled meat or fish fry and increase the amount of fruits and vegetables. Drink plenty of fluids, especially water, up to six to eight glasses a day. Even more vital than any of these tracks. Walking is the best exercise for cardiac surgery and postoperative part of your daily life from now on.

Wound Care

The intention is for all the wound healing without any complications. Secondary infection may lead to disruptions of the healing process and added suffering. The main sign of infection is always a pain. The body will tell you when there is a problem and the pain is always primary. Other signs of complications include redness, warmth, swelling, increased drainage, foul odor and a high temperature. Hand washing is the most radical way to prevent the spread of infection. Wash your hands often and thoroughly for 20 seconds with soap and water. Remember the ABC song or sing happy birthday! It takes only 20 seconds! Wash your hands before and after using the toilet, eat, perform wound care and medication.

Keep your wound care supplies in a plastic container with a tight lid away from children and pets.
How to write your own skills of wound care

If you own and you exactly how the order of wound care was written or not the order will change your documentation should reflect these changes. Thus the beginning of the early writing ability of the physician self-regulation. Although your doctor may prescribe a short and sweet of the order should reflect the diagnosis, all supplies and how often it will be the implementation of the wound itself. Written in the right way, the order can then be written in the note each nurse without any problems and you will always be consistent with doctor's orders for wound care. Of course, always double check the text of the unwritten you write in your comment! Keep the order as general as possible, or tell you that the brand name Kerlix, gauze rolled say more.

An example is: to__________site wound care as follows: the website cleaned with normal saline, dry, aggregate use of water cell, covered with gauze, still made the tape, the patient underwent treatment wounds without any problems, waste disposed of properly. Caregiver to perform wound care by specialist nurses day is not present.

Another example may be the use of the vac pack. Aseptic and sterile supplies _____________site wound cleaned with normal saline in a circular motion to the outside, dry, see-through dress to the site with an area of ​​wound left open wound filled with foam (add black or white and forget not indicate why and where the white foam is used and the number of pieces) cut to size, transparent dressing covered with foam with a hole for the tube, round tube used on the foam dressing and a transparent front to secure the area surrounding the pipe. Pac vacuum hose connected to the set pressure to ____ mmHg, the patient underwent wound care waste was removed and the patient is aware that the pressure must be maintained on the systematics. Patient demonstrated that amount of time on the package ACC can be found by the nurse at each visit. The patient is asked to put the machine on the field when the patient is at rest to keep the battery charged.

Of course, you should always add the wound looked, smelled, tasted ... just check to see if you pay knowingness j.

Aseptic and sterile supplies shows that you use to fix the principles of infection control, such as the use of PPE and good hand washing techniques. Hand washing should be taught with every patient, but where the prospects of supra infection present. Documentation of the quality of education are important and how to make hand washing, a vital part of your daily nursing note. Make sure you double bag technique with the use of your Wal-Mart bag or a trash bag for your dirty wound care than the garbage bag and place in the band of the patient before leaving the house.

Make sure you tell your patients that you wash your hands every time you do it to view and clean your equipment before your patient before by far. Make sure that you often take your gloves and wash your hands before making a new pair of gloves. Make sure you never in your bag without reaching the first hand washing, it tο see your bag is zipped following yοu get your supplies when you put out and cleaned yοu BP cuff, back in Steth

Writing a Foley catheter yοu men how changes

Using aseptic technique and sterile supplies οf the ball ____fr____ml Foley catheter changed vs follows: increase supplies to patients due tο installed, the new balls tested ______ml Foley οf οf liquid withdrawn from the catheter and the catheter removed without difficulty old , wash hands, new gloves, lubrication guide οf Foley catheter, cleaning οf meatus done using three Betadine swabs in a spherical outer movement, placing οf Foley performed without any problems, urine color caused οf urinary led to drainage bag hanging on the point be___________new waist circumference of patients, patiently endured the road properly, waste disposed as he was well again.

By placing a catheter, Coude sure to document that the red dot on the pigtail was noted in place, it will show you bend properly recorded and caused no damage.

The main cause no damage has been our motto and nurses in the best way to prove it with your documentation.

I think the more you say instructions, written instructions and guidelines for the more you produce a good practice and your visit will be smooth and your documentation will be better. Not to mention the more you informed of all the different impairment of normal physiological function that come your way in the nursing home and inviolable med surgical nursing, you will eventually do. All this will affect the quality of the care you give your patients is our number one understanding of each. Patients are primary in all things and their well-being and ability to secure one of their own home as long as possible is our goal.

I'm sure you all can add your own cheat sheets Blurbs these and it's a smashing way to ensure that you also learn to write the same every time your patients.

File your own note cards or add each new reduction process of normal physiological function that comes your way. Use the teaching guides in the workbook outside Angies office and mark the points you have learned. Using the grid, Medlinplus is a great source of information selectively Laymen terms you can subscribe to your patient, even print your notes for nurses. Or you need a computer, then use the library or ask your supervisor for more information selectively or not we are not a textbook to be used for this process.

The most important thing is that your training and documentation on the exact same thing, you can not just write instructions on the degradation of normal physiological functions, the process, learned about food, educated in infection control, management instructions on med. You should write all this no note or nurses are not able to understand the explanation of the reason for your being. Medicare and in truth, all insurance, our audit work at any time and regardless of whether the documentation is missing, the money paid to the agency once again returned. Worse than that is the responsibility you take if your documentation is not reasonable and necessary care to help. It would be terrible to sit in the courtroom by one, two or ten years from now with your comment seems to nurse a whole wall for all to see. If your score is on the wall, you can prove that you care provided in the rules and regs of CMS?

Or it was not written?

And here many of the other

Cheat sheets for documentation of your

Use and receive happiness!


A reduction in the normal physiological function of the lungs consists of chronic bronchitis and emphysema. It causes the small alveoli and alveoli of the lungs to tighten and close, allowing you short of breath with or without action. Medications such as bronchodilators and nebulizer treatments will help keep your airways open and aggravate the inflammation, but should never be abused. Many steroid inhalers around, these problems may or may not cause too much use.

Dense in calories are the best foods to eat when your body burns more calories while trying to breathe. It is also essential to never eat three meals a day if the food is heavy and causes shortness of breath. T is better to snack throughout the day, small, popular food to eat, drink to your lungs moist, mucus and cough to help.

Opposition to tell your SN / MD include shortness of breath, changes in color or stability of your sputum, blood in your sputum, increased heart rate and changes in mental status.

Whether or not you become short of breath long before sufficient oxygen will decrease your blood, your brain will cease and the critical functions of oxygen to survive. The confusion is an indication of not enough blood to your brain and your conclusions can threaten your well-being. It is the center you see a doctor for worsening dyspnea.

One of the things essential for a patient with COPD to remember is to increase liters of oxygen per minute, without their doctor! Whether or not the oxygen content is increased, the body of a patient with COPD to have disorientation, difficulty breathing, changes such as myopia and imagination. The prolonged or high concentrations of oxygen can cause oxidative damage to cell membranes, the collapse of the alveoli in the lungs, retinal detachment, and convulsions.

Symptoms of pulmonary toxicity caused by inflammation that starts in the airways leading to the lungs and then spreads to the lungs (tracheobronchial tree). The complaints come in to the upper chest (substernal regions and hull). It starts as a gentle tickle on inhalation and progresses to coughing popular. The patient is not breathing elevated partial pressure of oxygen is not interrupted, patients avoid a slight burn when inhaled, with all the uncontrollable coughing and shortness of breath occasional (dyspnea). Physical examination related tο pulmonary toxicity have been integrated bubbling sounds heard during a stethoscope (bubbling rales), fever and increased blood flow tο οf inside the nose (nasal mucosa hyperemia οf). Thе radiological result from thе lungs show inflammation and swelling (pulmonary edema). Condensed lung capacity, as raised by a fall in the air to measure οf the lungs can hold (critical capacity) and changes in expiratory lung function and elasticity.


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