Home health is based on the model of the nursing process.
1) What is the problem?
2) Define exactly what the problem is (this is the nursing diagnosis.)
3) Formulate a plan to correct the problem.
4) Implement and document on the plan.
5) Evaluate the plan.
6) Start all over again.
It is not nursing based; this is the patients care plan. All of the nursing care must be aimed at the patient. That is why nurses ask the patients “What are your goals for your home health care? What do you want to see happen in the next two months?” Al of the patients goals get set into field 22 of the OASIS (Outcome and Assessment Information Set) and in field 21 the nurse must put how, when, where, what those goals are going to be met. Every instruction or procedure must have a specific, realistic, amount (in percentage) and timely (in days, weeks or months) goal.
I realize you knew all that already, that was just a refresher.
Now, with instruction, comes a big responsibility. If you are very lucky, you will be the only nurse n that patient’s home. That is a nice fantasy isn’t it. In the real world, try as we might, patients may see several different nurses. This is true and guess what? Not all nurses instruct in the same way. Now, how do you become the nurse that everyone comes to for the CORRECT answer?
Home Health nurses must know their medical surgical nursing without fumbling through a handbook or looking it up on their point of care laptop or reading it off a sheet of paper. Moreover, all home health nurses worth their salt will instruct. It is one of the standards that Medicare expects from all home health nurses. How do you learn all those disease processes? Time, watching, reading, asking questions, studying, and knowing your patients so well that when they so much as breathe differently your ears will perk up! Another thing that does not hurt is something nurses did before laptops. They bought note cards and wrote the disease process on one side and on the other side, they numbered one through four.
1) Definition of disease process
2) Signs and symptoms to report to the skilled nurse and or the physician
3) Methods or ways to manage the disease process
4) Complications to report if all the above is not followed.
Not difficult at all and it works. Very old fashioned you say? Well, maybe so, but like I said, it does work. What will NOT work is not instructing at all then writing that you taught on something. Eventually someone will ask you to prove what you taught. Best hope it is only your supervisor and not a state surveyor or worse, a Medicare surveyor!
Which brings us to the last point of instruction and that is the documentation. Many times the disease process is just too lengthy to go through all for things that need to be covered. That is all right. It is better, actually, to break it up into chunks and make sure at the start of every visit that you ask the patient to repeat what they recall from the previous visit. This is your progress towards goals and you need to be documenting it specifically as well. Besides, it looks so good during a supervisor visit or a survey visit when you tell your patient “OK its homework time! Can you tell me something you learned from my last visit?” now you have your progress towards goals documented and all the check boxes done and you document on the negative findings. Then you document the specific skill. Many times, instruction is going to be your only skill I dreaded these types of hoe health episodes. It is these charts that will be scrutinized along with your most complicated patients. Why? Because every note must stand-alone. Every patient must have proof, indisputable written proof, hopefully with quotes and examples and percentages from and about the patient that what you as a nurse did improved that patients health and well-being. Not to forget, even with a complicated wound or intravenous meds or TPN (Total Parental Nutrition) you must still instruct on the top three disease processes on the Oasis!
Also, do not forget that in 2012, Medicare will decrease the PPS (Prospective Payment System) and the second reason Medicare is doing this is why? Because from a survey of many home health agencies across the country it could not be proven that, the patients had improved under the care and instruction of the home health agencies. That means us. That means as nurses we did not act responsibly or as a prudent nurse should act. Embarrassing, is it not.
If you have point of care, you may have all your disease processes plugged in and all you have to is cut and paste for your documentation.
How nice,
Will it teach you med-surg nursing? Will it instruct your patient on what they need to know to improve their health? Will it pass muster if someone asks you a specific question that is not on your point of care? Not your boss; I am talking about your patient. After all, you can only say, “I will get right back to you with that on my next visit” so many times.
In summary what do we, as home health nurses, need to do in order to improve the care and health of our patients?
1) Learn Medical surgical disease process, definitions, signs and symptoms, methods to manage and complications that can result.
2) Repeat this information to our patients in as many visits as it takes.
3) Ask our patients on every visit to repeat what they learned the previous visit back to us.
4) Document in our nurses notes exactly what the patient was able to recall. This information goes under progress towards goals.
5) Document your skill.
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