Category Archives: documentation

Documentation Made Easy


The Basics

Right Chart: Check that you have the correct chart before writing.

Penmanship: All your documentation is to be legible so anyone can read it. If you have poor penmanship, begin to print. Your printing will make it easier to read your notes. Now that your nursing notes are legible, let’s talk about the basics. Use permanent black ink pen. Other colors do not copy well.

Date and Time: Date and time every entry. The date should include the year; the time should indicate am or pm or be in military time. Don’t chart in blocks of time such as 0700 to 1500. This makes it hard to determine when specific events occurred.

Client’s history (including unhealthy conditions or risky heath habits such as scalp lice, smoking, failure to take prescribed medication, specific non-compliance issues and events, etc.) A client’s history is usually reflective of trends and may offer valuable hints about what to expect in the future.

Subjective Information: It is important that you chart any subjective information. Document what you hear, what the client says, what the caregivers say, comments to you about how they feel, feelings of anxiety or depression, etc. Use direct quotes and place quotation marks around the quote. Chart a client’s refusal to allow a treatment or take a medication. Be sure to report this to your immediate supervisor and the client’s physician and document your calls.

Objective Information: Chart your observations, what do you see, vital signs, hard data such as any and all assessment information. It is especially important to document changes in health status such as the emergence of a productive cough, difficulty in breathing or changes in vital signs from their baseline. Did you address: mental status, functional status, mobility, cognitive ability, speech? Oftentimes when you are in the home every day you forget that the people reading your notes do not know the client so you need to show them on paper.

Interventions: Document any actions that you did in response to any of your observations and the client’s response to your actions. These responses to your interventions are commonly called client outcomes. Chart the time you gave a medication, the route you gave it and the client’s response. If a medication is a PRN, chart the reason it was given and the client’s response to the medication (did it give the desired effect). Chart precautions, preventive measures used as well as any safety measures enacted, such as bed rails.

Client outcomes: Chart the client’s response to your interventions, including those that are deviations from what you expected. For example: if a client is in pain, observe and document how that pain is experienced both objectively (what you see) and subjectively (what you hear). Record where the pain is and the level of intensity or severity (use a pain scale to do that). Record the medication and the backrub you give to relieve the pain and whether or not those actions were effective, i.e., did the pain persist, recur, or go away?

Document the client, family member or significant other’s actual response (verbal or non-verbal) to any aspect of care provided even if you were not the one providing it. Doing so indicates that you have evaluated the results of care. It is perfectly acceptable to chart the client’s verbal responses in the record as long as you use quotation (“) marks. Non-verbal responses should be described in as much detail as possible.

Make sure your documentation reflects the nursing process and your professional capabilities. Chart completely, concisely and accurately (“Tell it like it is.”). Write clear sentences that get right to the point. Use simple, precise words. Don’t be afraid to use the word “I.”

Be sure to record your full name, credentials and job title in the required section on documentation forms. Some forms will ask you to record your initials as well. Your signature must be in cursive writing so a word of final caution: do take the time to sign your name legibly.

Beyond The Basics

Client Education and Instruction: Other information that needs to be recorded in the medical record includes any education or instructions you give to the client, his family or significant other. Anytime there is a new medication or treatment the client, family member and other personnel must be educated and informed. Documentation of these actions is required. Include the fact that you informed the client/caregiver of the new order; chart the education of dosage, actions, side effects and schedule; chart that you made changes on the medication administration record or task sheets (if applicable); chart how you were able to communicate the new orders to other nursing personnel responsible for the client’s care, document your communications regarding the new orders to the office.

Check Off Sheets: In some instances a preprinted, standardized check off form may be used where all you have to do is check off or initial what you have done. The only time you may have to write any notes is when something is specific or unique to this particular client, something that can’t be included on a standardized check off form. Remember: if you do not check off items, it means that legally the care was not done.

Phone Calls: We don’t often think about phone calls, but they can contain certain information for which we have obligations such as advice that we may give to a client or a phone order that we may take from a doctor. To protect yourself in these kinds of phone conversations, a detailed summary of your conversations is charted in the client record.

Details of each call should include:

  1.  Date and time of the call
  2. Caller’s name, position or credentials, call back phone number and address
  3. Reason for the call, request, complaint
  4. Your response to the call, advice you gave, protocol you followed (if applicable)
  5. Others that you notified as a result of the call
  6. Your name and credentials
  7. If taking doctor’s orders, transcription of the orders word for word and documentation that you read the orders back for verification.

More Do’s to Make Charting Successful

  • Chart as soon as possible after giving care; don’t wait to chart until the end of your work day. Chart often enough to tell the whole story.
  • If you remember an important point after you’ve completed your documentation, chart the information with a notation that it’s a “late entry.” Include the date and time of the late entry.
  • Chart all of the details relating to visits by physicians or other members of the health care team such as the teacher, therapist, case worker, dietician, social worker, etc. Describe the purpose of the visit, the name of the visitor, the time spent with the client and the outcome of the visit.
  • If you don’t give a medication, circle the time and document the reason for the omission.
  • If information on a form such as a flow sheet doesn’t apply to your client, write NA (not applicable) in the space provided.
  • Use only commonly used or approved abbreviations and symbols. Refer to the procedure manual for a list of approved abbreviations. When in doubt spell out the words. Remember many medications have similar names but very different actions.
  • When documentation continues from one page to the next, sign the bottom of the first page. At the top of the next page, write the date, time and “continued from previous page.” Make sure each page contains the client’s identifying information, date and year.
  • Re-read your documentation. You need to paint a picture of the client. Pretend you know nothing about the client. Then read your notes and see if your notes are capable of making you see the client as he/she really is.

-By Janet Fulfs, President

Note: First published on American Home Health's news, October 2011.

Health Literacy


One of our goals this year is to improve our client’s ability to take their own oral medications. Toward this end, we recognized the need to better educate our nurses to recognize their client’s inability to read and/or write and to give you the tools to better serve this population with limited literacy levels.

Health literacy is the ability to read, understand and act, on medical information. It is up to the nurse performing home care to adequately assess the patient’s literacy level in order to determine if they are taking their medications correctly. Limited health literacy is likely linked to medication errors. It is ultimately important to educate them to take their medications as ordered to keep them out of the hospital. The average American reads at an 8th grade level, we regularly impart information at a college level.

Assessing Literacy

Illiteracy is hard to spot, so pay attention to verbal and visual cues. Does your patient put off reading or filling out forms, or does she ask a relative or friend to read them for her? Does she tell you she can’t find her glasses? Does she get defensive when you ask about material she should have read? When you hand her written instructions or forms, does she quickly put them aside or look at them upside down?

Ask your patient about her vision and reading skills; if necessary, use these techniques to assess her literacy level. Ask open-ended questions. Once you give her written instructions, try to find out if she’s read and understood them by asking questions that require more than a yes-or-no answer. For example, instead of “Do you understand this consent form?” say, “Would you please describe what’ll happen to you during this procedure?” If she can’t answer or answers incorrectly, she may need more help to understand or she may be illiterate.

Informally test her skills. If you strongly suspect that your patient is illiterate but you’re unsure, you might give her a written brochure on breast self-examination (BSE). Allow her 10 minutes alone to read it. Then ask her to demonstrate the technique. Or hand her an appointment slip or a medication insert from the pharmacy and ask her to read it aloud while you change her dressing. If your patient can’t read aloud or demonstrate a technique, she’ll probably be embarrassed. Keep things low-key and show that you care. Reassure her that she’s not the first person to have a reading problem and that she can learn about her health in many other ways. Tell her that you’ll keep her inability to read as confidential as possible but that you’ll need to tell her health care provider and other nurses.

Teaching without written words

Okay. You’ve determined that your patient can’t read or write. Now how do you teach her what she needs to know about her condition and care? Here are some common sense tips:

Speak simply. Keep your messages short, clear, and specific, and use active voice. For example, tell your patient, “If your heart rate goes below 60 beats a minute, call your health care provider before taking this pill,” rather than “There could be a slowing effect on your heart.” Put enthusiasm in your voice, gestures, and facial expressions to keep her interested. Just don’t overdo it.

When you explain one of the patient’s medications to them, tell them the name, the use, one effect and one side effect. Then have them repeat it back to you. Slow down. Don’t speak so quickly so the patients can understand what you are saying. Patients can only remember 1, 2, or 3 things from a conversation. Ask them to repeat back to you what you have told them. Use language the patient can understand. Say high blood pressure, not hypertension. Convey only the most important concepts.

Use appropriate examples. Consider your patient’s age, sex, occupation, and interests before giving examples. If she loves to cook, explain that 30 ml of potassium elixir equals 2 tablespoons. Repeat and question. Give her important information more than once and allow plenty of time for questions and answers. Keep asking: “What questions do you have?” and “What would you like me to go over?”

Ask for return demonstrations. Make sure your patient demonstrates each step of every procedure you teach her. Take the extra step of asking the patient to demonstrate back. When asking patients to “teach-back” or “show me”, clinicians should preface their request by placing blame for poor understanding not on the patient, but on themselves (the treating clinicians). For example, phrasing the request as-“Can you show me how you’re going to do this when you get home? I want to make sure I did a good job explaining this to you”-clearly places the onus of learning on the teacher, not just the learner. The teach-back method not only can uncover misunderstanding, but also can reveal the nature of the misunderstanding and thereby allow for corrective, tailored communication.

Involve the patient in your teaching. Show her the care plan and ask for her input. As you work through the problems and goals, ask for her perceptions. Treating her as a partner encourages cooperation.

Use pictures. Writing “Take each dose with two glasses of water” won’t work with an illiterate patient, but she’ll probably understand a drawing of a pill, a water faucet, and two filled glasses. Draw them yourself or look for art in brochures or online.

When you teach involve family members. Use visual aids in what is going on, use examples. Use a medication sheet, what med to take, what time to take med, what med is for. Don’t say do you understand the medication. That will be the end of the conversation. Say, “tell me, what is the medication for? What is the side effect that is most common? Why do you take the medication? Employ teach back method. Have the patient teach you. Because of the tremendous variation in learning preferences, providing patients with a visual demonstration can enhance communication, but by no means guarantees future success.

Use a medication dispenser. You can teach a family member, or teach the patient. Use 1 dispenser for daily, use 2 daily dispensers for twice a day or use the 4 or 5 times a day x7 day dispenser. It is useful each time you finish filling the dispenser with one medication, to turn the bottle over to remind you that no longer need that med. Put the pills on a heavy weight paper sized (8 ½” x11″) cardboard by gluing or taping them, to demonstrate one day of medication. This will only be useful if there is a limited amount of pills/day.

Give her videotapes. Videos may be available in your facility’s library or you could make your own. Follow your facility’s protocol for videotaping procedures for patient use. Make audiotapes. If commercial tapes aren’t available, make your own. Turn on the tape player and clearly explain each step of a procedure as you perform it. You can also have your patient make a second tape explaining the steps in her own words as she performs them while you supervise. Audiotapes work for other types of teaching too. For example, if your patient’s taking a new medication, tell her about common adverse responses, how to combat them, drug interactions, and dosages.

Document your teaching. Record your patient teaching and how you verified her understanding in the medical record. Helping any patient stay as well as possible can be challenging, but an illiterate patient is especially hard to reach and teach. By combining common sense and caring, you can break through the illiteracy barrier.

The Most Important Document


Home Healthcare Documents
Form CMS-485 (Plan of Care)
“The Most Important Document”

Home Health is known for its plethora of documents, but one form stands out amongst them all: the “Plan of Care” also called the “485” after its Center for Medicare/Medicaid Services document No. CMS- 485.

This document is so important because it is the so called “Mother Document.” Plans of Care combine the orders of multiple medical disciplines into one document. This comprehensive authoritative Document governs many of the forms in the home chart and the actions of the nurses providing care. Each 485 contains the Patient and Provider demographics, Medication orders, Nursing orders, Diagnosis/Procedure Codes, Supply lists, Nutritional requirements, Allergy info, Patient Activities/Limitations, Ancillary care orders (OT,PT, etc.), Goals and Discharge plans, and a Penalty statement for falsification, misrepresentation or concealment of essential information on the form.

According to CMS rules the Patient must be evaluated and the Nurses supervised and orders rewritten at least every sixty days. All Therapies and medications listed become Doctors Orders once signed. All other documents (i.e., Medication Administration Record) in the home chart should follow the orders listed on the 485, except interim orders written/signed after the date of the 485. The 485 should be the “Go To” document when unsure, or verification of Rx/Tx’s is needed.

Keeping the 485 updated and accurate, is the responsibility of all Care Providers utilizing it as a fiduciary document to authorize their professional services. The 485 is edited by the Nursing Supervisor and endorsed by the Doctor every 60 days, but in-between that period the plan is adjusted and tuned to match the Patients dynamic condition. Medications are changed, diets are adjusted or therapies may be started. When these interim alterations occur, it is each caregiver’s responsibility to verify if needed and pass on to the Nursing Supervisor proof of such changes in a timely manner so the 485 will be accurate the next certification period. Verification can be done via phone calls/faxes and Verbal/Telephone (VO/TO) orders forms. Clear, timely and accurate communication is the best prophylactic therapy professional caregivers can administer. Consistently checking the 485 and interim orders w/ timely communication is the bridge to good continuity of care. All interim order copies should be kept with or near the 485 for reconciliation by all caregivers.

Utilizing and maintaining the Plan of Care CMS- 485 is serious business, not to be taken lightly. Let me quote the responsibilities charged in the Illinois Nurse Practice Act: “The administration of medications and treatments as prescribed by Physician…a Dentist…Podiatrist…Optometrist…PA…APN. The coordination and management of the Nursing Plan of Care.”

Please pay attention to this important document and communicate with your Nursing Supervisor. Your Patient, his/her PMD and your fellow caregivers will love you for it.

by Shawn A. Pickett, MSN, RN

First published on American Home Health's Newsletter, December 2008.