Mock Patient - Nursing

You will complete the following:

1) New admission assessment, develop a care plan, develop interventions based on care plan, enter in medications

2) Daily assessment with narrative notes

3) Complete interventions

4) Medication administration

5) Verbal order

Patient Name:

Pick a patient from your “client list” – you will see you assigned as the clinician. You will do this for each patient assigned

to you as a way of familiarizing yourself with Kantime and home health charting requirements.

History per mom’s report:

Home residents: Mom (primary informant), father and 2 siblings (you can make up names and ages) Primary language of child: English History: 10 y/o male with Hunter Syndrome Patient has trach and on ventilator with current settings: Rate 20, PIP 20, PEEP 5,

I:time 0.25, 21-24% FIO2. Trach size 4.5. Mickey button, 12 FR size feeding tube, inflatable balloon.

Current weight: 67 lbs.

MEDICATIONS - current

Plan of Care

This will be the plan of care when all information is entered into Kantime from this mock patient information.

(21) - Orders for Discipline and Treatments (Specify Amount / Frequency / Duration)

Frequency

48 hours per week due to declining health status.

Treatments

Skilled Nursing

EQUIPMENT CHECKLIST

ORAL CARE SUPPLIES: VERIFY STOCK WEEKLY AND NOTIFY CG OR DME SUPPLIER IF MORE NEEDED.

FEEDING PUMP: CHECK FUNCTION AND WIPE CLEAN Q SHIFT.

FEEDING BAG: RINSE BAG WITH HOT WATER AFTER EVERY USE.

GTUBE: _14_FR _2_CM; MICKEY/BARD WITH EXTENSION SET.

NEBULIZER: WIPE DOWN UNIT Q SHIFT.

OXYGEN TANK: CHECK TANK LEVELS Q SHIFT AND RECORD.

OXYGEN CONCENTRATOR: WIPE DOWN UNIT PAYING SPECIAL ATTENTION TO AIR INTAKE GRID AND CLEAN FILTER Q WEEK.

PULSE OXIMETER: ROTATE PROBE SITE(S) Q SHIFT.

PULSE OXIMETER: WIPE DOWN UNIT Q SHIFT.

SUCTION MACHINE: CHANGE SLEEVED CATHETER Q DAY AND PRN.

SUCTION MACHINE: EMPTY CANISTER AND WASH WITH HOT SOAPY WATER AND RINSE WITH HOT WATER Q SHIFT AND PRN.

SUCTION MACHINE: WIPE DOWN UNIT Q SUNDAY.

SUCTION CATHETERS: INLINE SUCTION CATHETER, DEPTH TO 7 (DOUBLE RED LINE).

HUMIDIFIER: EMPTY CHAMBER, WASH IN HOT SOAPY WATER, RINSE IN HOT WATER, AND ALLOW TO AIR DRY AFTER EACH USE.

HUMIDIFIER: FILL WITH STERILE WATER PRIOR TO EACH USE.

AMBU BAG MASK: WASH WITH HOT SOAPY WATER, RINSE WITH HOT WATER, AND ALLOW TO AIR DRY AFTER EACH USE.

HOSPITAL BED: CLEAN HANDRAILS WITH DISINFECTANT WIPE Q SHIFT.

TRACH: IN CASE OF EMERGENCY, MAINTAIN SAME SIZE AND ONE SIZE SMALLER TRACHS WITH OBTURATORS, PRE-MEASURED TRACH TIES,

WATER-SOLUBLE LUBRICANT, AND AMBU BAG WITH MASK AT BEDSIDE AT ALL TIMES.

BATH/SHOWER CHAIR.

LIFT DEVICE: CLEAN SLING PER MANUFACTURER'S DIRECTIONS AND WIPE DOWN SUPPORTS WITH DISINFECTANT WEEKLY.

WHEELCHAIR: WIPE DOWN WITH A CLEAN, DAMP CLOTH WEEKLY AND PRN SOILING.

STANDER: CHECK STRAPS AND VERIFY GOOD WORKING CONDITION WEEKLY.

GASTROINTESTINAL

SN FOR INSTRUCTION/REINFORCEMENT OF ADMINISTRATION OF GASTROSTOMY FEEDINGS INCLUDING SAFETY MEASURES, TUBE

PLACEMENT, CARE OF EQUIPMENT, AND PREPARATION OF FEEDINGS.

SN TO PROVIDE INSTRUCTION/REINFORCEMENT ON FEEDING PRECAUTIONS AND MEASURES TO PREVENT ASPIRATION.

SN FOR ADMINISTRATION OF GASTROSTOMY FEEDINGS. SN TO VERIFY PROPER INFLATION OF BALLOON Q WEEK AND PRN.

SN TO ASSESS G-TUBE PATENCY PRIOR TO EACH USE.

SN TO PERFORM G-TUBE CARE AS NEEDED

GENITOURINARY

SN TO PROVIDE INSTRUCTION/REINFORCEMENT RELATED TO GENITOURINARY DISEASE INCLUDING COLOR OF URINE AND S/S OF INFECTION.

IMMUNOLOGIC

SN TO PROVIDE INSTRUCTION/REINFORCEMENT REGARDING INFECTION CONTROL MEASURES.

SN TO OBSERVE AND ASSESS PT FOR S/S OF INFECTION AND REPORT TO MD ANY SIGNIFICANT S/S IDENTIFIED.

INTEGUMENTARY

SN/CG TO PROVIDE BATH AND SKIN CARE AS ORDERED DAILY TO MAINTAIN PATIENT INTACT INTEGUMENTARY STATUS AND PREVENT

INFECTION.

SN/CG TO PROVIDE ORAL CARE Q SHIFT AND PRN TO MAINTAIN HEALTHY MUCOUS MEMBRANES AND PREVENT INFECTION.

SN/CG TO PROVIDE PERICARE Q DIAPER CHANGE AND PRN SOILING.

SN/CG TO PROVIDE APPROPRIATE CARE FOR PT WITH LIMITED RANGE OF MOTION.

MEDICATION

SN TO PROVIDE INSTRUCTION/REINFORCEMENT REGARDING NEW AND CHANGED MEDICATION AND MEDICATION REGIMEN.

SN TO PROVIDE INSTRUCTION/REINFORCEMENT REGARDING ADMINISTRATION OF LOVENOX INJECTION AS ORDERED BY MD.

SN TO ADMINISTER MEDICATIONS AS ORDERED BY MD.

SN TO ASSESS AND MONITOR EFFECTIVENESS OF MEDICATION REGIMEN.

SN TO ASSESS CG'S KNOWLEDGE/COMPLIANCE WITH MEDICATION REGIMEN AND PROVIDE INSTRUCTION/REINFORCEMENT PRN FOR

DEFICITS.

SN MAY ADMINISTER NEW AND CHANGED MEDICATIONS AFTER PRESCRIPTION FILLED BY PHARMACIST.

MUSCULOSKELETAL

SN TO APPLY ORTHOTICS (AFO/KFO) AS ORDERED DURING DAYTIME AS INDICATED BY THERAPIST OR MD ORDER.

SN TO ASSESS SKIN Q 2 HOURS AND PRN.

NEUROLOGICAL

SN TO PROVIDE INSTRUCTION/REINFORCEMENT RELATED TO SAFETY MEASURES TO PREVENT INJURY SECONDARY TO IMPAIRED

NEUROLOGICAL STATUS AND/OR SEIZURE DISORDER.

SN TO MONITOR AND DOCUMENT ANY SEIZURE ACTIVITY. NOTIFY MD FOR PROLONGED SEIZURE ACTIVITY AND/OR IF UNRESOLVED BY PRN

MEDICATION ADMINISTRATION.

PAIN MGMT

SN TO PROVIDE INSTRUCTION REGARDING MEDICATIONS PRESCRIBED FOR PAIN CONTROL INCLUDING DOSE, ROUTE, FREQUENCY,

PRECAUTIONS, AND SIDE EFFECTS.

SN TO FOLLOW CURRENT PAIN REGIMEN AND REPORT/DOCUMENT ALL FINDINGS AND RESULTS.

RESPIRATORY

SKILLED NURSE TO MONITOR AND ASSESS RESPIRATORY STATUS INCLUDING DYSPNEA, LUNG SOUNDS, CHANGE IN COLOR/CONSISTENCY OF

SECRETIONS, AND USE OF ACCESSORY MUSCLES FOR BREATHING.

MAY APPLY HEAT MOISTURE EXCHANGER (HME OR ARTIFICIAL NOSE) OVER TRACH FOR HUMIDIFICATION AS ORDERED PER MD.

SN TO PROVIDE INSTRUCTIONS/REINFORCEMENT OF TRACHEOSTOMY CARE, INCLUDING STOMA CARE, SUCTIONING, AND CHANGING TRACH

TIES/DRESSING.

SN/CG TO KEEP SPARE _4.0_TRACH AND SPARE (ONE SIZE SMALLER) _3.5_TRACH WITH OBTURATORS, WATER-SOLUBLE LUBRICANT, TRACH

TIES, STERILE GAUZE AND TAPE, AMBU BAG AND MASK, AND OXYGEN WITH PT AT ALL TIMES.

SN TO SUCTION TRACH USING _10_FR SUCTION CATHETER TO A DEPTH OF _7_CM AT TRACH HUB PRN CONGESTION, INCREASED SECRETIONS,

OR RESPIRATORY DISTRESS. STERILE NORMAL SALINE MAY BE INSTILLED INTO TRACH DURING SUCTIONING PRN THICK SECRETIONS AS

INDICATED PER MD.

SN TO CHANGE TRACH PRN FOR DISLODGEMENT OR OCCLUSION, CG CHANGES TRACH WEEKLY ON SUNDAYS.

SN/CG TO CHANGE TRACH TIES WITH EACH TRACH CHANGE AND PRN AFTER BATHING, SOILING, OR SOAKING.

SN TO ASSESS AND DOCUMENT PATIENT'S OXYGEN SATURATION Q _2 HRS_ AND PRN S/S DYSPNEA, CYANOSIS, INCREASED WORK OF

BREATHING, ETC. PULSE OX SETTINGS: HIGH HR _140_; LOW HR _50_; HIGH SAT _100_%; LOW SAT _90_%.

PT TO BE MONITORED BY PULSE OXIMETRY CONTINUOUSLY AND PRN S/S RESPIRATORY DISTRESS.

SAFETY

SN TO PROVIDE INSTRUCTION/REINFORCEMENT REGARDING CHILD'S ENVIRONMENTAL NEEDS R/T SAFETY.

SN TO ASSESS RISK FOR TRAUMA RELATED TO PHYSICAL HELPLESSNESS Q SHIFT. SN TO INSTRUCT CG'S WHERE DEFICITS ARE IDENTIFIED.

SN TO ASSESS CLIENT'S HOME SAFETY Q SHIFT AND PRN CHANGES.

SN TO KEEP SIDERAILS UP WHILE PT UNATTENDED IN BED.

STANDARD ORDERS

SN TO PROVIDE EDUCATION/INSTRUCTION AND REINFORCEMENT TO CAREGIVER AND DOCUMENT RELATED TO CARE OF PATIENT DISEASE

PROCESS.

IF AGENCY IS UNABLE TO MEET THE STAFFING NEEDS OF THE PT, PARENT/CG IS RESPONSIBLE FOR PROVIDING PT'S CARE ACCORDING TO

CARE PLAN.

SN TO PERFORM HEAD TO TOE ASSESSMENT Q SHIFT AND PRN IF CHANGE IN STATUS.

OBSERVE/ASSESS/MONITOR PT'S CONDITION FOR CHANGES AND/OR COMPLICATIONS R/T DISEASE PROCESS AND/OR MEDICATION AND

TREATMENT CHANGES.

NEAR END OF CURRENT CERTIFICATION PERIOD, PT WILL BE ASSESSED BY REGISTERED NURSE FOR RECERTIFICATION.

(22) - Goals / Rehabilitation Potential / Discharge Plans

Goals

Skilled Nursing

GASTROINTESTINAL

CG WILL VERBALIZE AND DEMONSTRATE/RECALL ADEQUATE KNOWLEDGE TO SAFELY ADMINISTER FEEDINGS PER _GASTROSTOMY_ TUBE.

CHILD WILL RECEIVE ADEQUATE NUTRITION AND TOLERATE GASTROSTOMY FEEDINGS AS ORDERED WITHOUT S/S OF FEEDING

INTOLERANCE OR ASPIRATION.

CHILD'S GASTROSTOMY TUBE WILL REMAIN PATENT THROUGHOUT CERTIFICATION PERIOD.

CHILD'S GASTROSTOMY SITE WILL REMAIN FREE OF S/S OF INFECTION THROUGHOUT CERTIFICATION PERIOD.

GENITOURINARY

CG WILL VERBALIZE/RECALL ADEQUATE KNOWLEDGE TO MANAGE GENITOURINARY DISEASE PROCESS THROUGHOUT CERTIFICATION

PERIOD.

S/S OF GU EXACERBATIONS WILL BE IDENTIFIED BY CG/SN AND PHYSICIAN NOTIFIED FOR PROMPT INTERVENTION TO MINIMIZE ASSOCIATED

RISKS THROUGHOUT CERTIFICATION PERIOD.

IMMUNOLOGIC

CG WILL VERBALIZE APPROPRIATE INFECTION CONTROL MEASURES TO PREVENT INFECTION OR CONTAMINATION.

S/S OF INFECTION WILL BE IDENTIFIED AND PHYSICIAN NOTIFIED FOR PROMPT INTERVENTION TO MINIMIZE ASSOCIATED RISKS

THROUGHOUT CERTIFICATION PERIOD.

INTEGUMENTARY

CG WILL DEMONSTRATE INDEPENDENCE AND KNOWLEDGE OF REQUIREMENTS TO MAINTAIN PT'S INTACT INTEGUMENTARY STATUS.

S/S OF SKIN IMPAIRMENT WILL BE IDENTIFIED AND PHYSICIAN NOTIFIED FOR PROMPT INTERVENTION TO MINIMIZE ASSOCIATED RISKS.

PT WILL MAINTAIN HEALTH INTEGUMENTARY STATUS FREE OF TISSUE BREAKDOWN AND/OR INFECTION THROUGHOUT CERTIFICATION

PERIOD.

PT WILL MAINTAIN HEALTHY ORAL CAVITY FREE OF INFECTION THROUGHOUT CERTIFICATION PERIOD.

MEDICATION

CHILD WILL RECEIVE MEDICATIONS AS PRESCRIBED WITH NO ADVERSE EFFECTS THROUGHOUT CERTIFICATION PERIOD.

CG WILL DEMONSTRATE/RECALL ADEQUATE KNOWLEDGE OF SAFE AND EFFECTIVE ADMINISTRATION OF MEDICATIONS PER REGIMEN AS

ADVISED PER MD.

CG WILL VERBALIZE USE, SCHEDULE, PRECAUTIONS, AND SIDE EFFECTS OF MEDS PRESCRIBED TO BE GIVEN BY INJECTION.

CHILD WILL RECEIVE ORDERED MEDICATION BY INFUSION AND DEMONSTRATE APPROPRIATE RESPONSE TO MEDICATION THROUGHOUT

CERTIFICATION PERIOD.

MUSCULOSKELETAL

CG WILL DEMONSRATE ADEQUATE KNOWLEDGE OF MANAGEMENT OF MUSCULOSKELETAL STATUS.

PT WILL MAINTAIN FUNCTIONAL STATUS AT CURRENT LEVEL THROUGHOUT CERTIFICATION PERIOD.

NEUROLOGICAL

CG WILL VERBALIZE/RECALL APPROPRIATE MEASURES TO PROMOTE SAFETY AND PREVENT INJURY DURING SEIZURE ACTIVITY

THROUGHOUT CERTIFICATION PERIOD.

S/S OF NEURO DISORDER WILL BE IDENTIFIED AND PHYSICIAN NOTIFIED FOR PROMPT INTERVENTION TO MINIMIZE ASSOCIATED RISKS.

PAIN MGMT

CG WILL DEMONSTRATE/RECALL ADEQUATE KNOWLEDGE OF PAIN MANAGEMENT.

CG WILL VERBALIZE/RECALL APPROPRIATE USE, SCHEDULE, PRECAUTIONS, AND SIDE EFFECTS OF MEDICATIONS PRESCRIBED FOR PAIN

CONTROL.

PATIENT'S PAIN WILL BE CONTROLLED WITH CURRENT PAIN REGIMEN AS ORDERED PER MD THROUGHOUT CERTIFICATION PERIOD.

RESPIRATORY

CG WILL DEMONSTRATE/RECALL APPROPRIATE CARE INCLUDING SUCTIONING, POSITIONING, AND ASPIRATION PRECAUTIONS THROUGHOUT

CERTIFICATION PERIOD.

CHILD WILL BE FREE OF AIRWAY OBSTRUCTIONS OR RELATED COMPLICATIONS DURING THIS CERTIFICATION PERIOD.

PT WILL REMAIN FREE OF S/S OF RESPIRATORY DISTRESS THROUGHOUT CERTIFICATION PERIOD.

S/S OF RESPIRATORY DISTRESS/INFECTION WILL BE IDENTIFIED AND PHYSICIAN NOTIFIED FOR PROMPT INTERVENTION TO MINIMIZE

ASSOCIATED RISKS.

TRACH STOMA AND SURROUNDING SKIN WILL REMAIN FREE OF S/S OF IRRITATION AND/OR INFECTION THROUGHOUT CERTIFICATION

PERIOD.

CG WILL DEMONSTRATE INDEPENDENCE IN CARE OF TRACHEOSTOMY.

CG WILL DEMONSTRATE INDEPENDENCE IN ADMINISTRATION OF ORDERED INHALATION THERAPY AND CARE OF RELATED EQUIPMENT

THROUGHOUT CERTIFICATION PERIOD.

PT WILL RECEIVE RESPIRATORY TREATMENTS AS ORDERED PER MD.

PT WILL REMAIN FREE OF THICK SECRETIONS AND MUCOUS PLUGS THROUGHOUT CERTIFICATION PERIOD.

SAFETY

CAREGIVER WILL VERBALIZE APPROPRIATE MEASURES TO PROMOTE SAFETY AND PREVENT INJURY IN HOME ENVIRONMENT.

CHILD WILL REMAIN FREE OF PHYSICAL INJURY THROUGHOUT CERTIFICATION PERIOD.

STANDARD ORDERS

PT WILL RECEIVE OPTIMUM PDN SERVICES THIS CERTIFICATION PERIOD. PT WILL REMAIN AT HOME UNDER THE CARE OF AGENCY, AVOIDING

HOSPITALIZATION, AND HAVE ALL SKILLED NEEDS MET. PT WILL REMAIN FREE OF S/S OF INFECTION OR RESPIRATORY DISTRESS AND

TOLERATE FEEDING.

DISCHARGE PLANS

PATIENT WILL BE DISCHARGED TO CARE OF FAMILY UNDER THE SUPERVISION OF MD WHEN SKILLED NURSING IS NO LONGER REQUIRED, AT

CAREGIVER/PARENT REQUEST, OR WHEN THE CHILD REACHES THE AGE OF 21.

----------------------------------------------------------------PLAN OF CARE – END----------------------------------------------------------------

Initial Admission Assessment

Below you will find all the current information on this mock patient to enter into Kantime for training purposes.

PDN nursing services to maintain current functional ability, to provide education to caregivers regarding disease process and medications. 10 y/o male with

Hunter Syndrome with tracheostomy and G-tube requiring skilled nursing intervention to maintain airway and prevent aspiration. SN will administer

medications as ordered by PCP. SN will perform trach care and maintain airway patency. SN will perform G-tube care and administer feedings and medications

as ordered. SN will monitor VS as ordered and document. SN will maintain skin integrity and notify MD of any skin breakdown. SN will monitor, document and

treat any seizure activity as ordered by MD. SN will provide oral hygiene as ordered.

---------------------------------------------------------Done with initial admission assessment---------------------------------------------------------

eCHART

This is what the tabs look like in your eChart (electronic chart):

Pediatric SN Visit – this is where your assessment and narrative notes are located. Interventions – this is where your required interventions are for your patient are located in. Goals – this is where you can view the goals set by your case manager for this patient. Medications – this is your MAR and where you will document medications administered. Notes – this is an internal notes communication ONLY. Use the narrative note section within in pediatric SN visit tab. Forms – these are various forms that you may need at some point. Documents – this is where, if needed, you can load documents relevant to your patient.

(Scroll over each icon in Kantime to learn what they mean (upper right hand corner). The printer icon will not print to a printer, it prints to the

screen and you can visualize what your chart looks like when we submit for reimbursement and what the state reviews during a survey.

It time to chart a daily shift assessment. Click on the EPISODE tab and look under schedules to begin eCHART which is your daily

documentation.

Vital Signs: Temp 98.8 B/P 110/67 HR 84 RR 20 02Sat 96%

ENT – PERRLA CV – regular heart rhythm noted, cap refill <3 seconds, no mottling, no shortness of breath with exertion, no edema, peripheral pulses palpable Resp – Lung sounds clear bilaterally, non-productive cough, Trach size 4.5, trach last changed on _____, ventilator (chart settings as noted above) and complete ventilator flow sheet and suction log. Pain – No pain noted GU / Nutrition – abdomen soft, normal bowel sounds all quads, Mickey G-button size 12 Fr, site clean/dry/intact, Formula (see above), Last BM last night Skin – skin temp is warm, dry and intact (although this patient does not have any wounds, please review wound care section/sheet Neuro – PERRLA, no seizure activity noted (please review seizure log for future charting), sensory loss noted ENDO/METAB – glucose – blood checked – result 82 Musculoskeletal – Non ambulatory, contractures noted on RUE and LUE, bilateral foot drop, uses wheelchair GU – urine clear yellow, incontinent EQIP – check all equipment at beginning of shift and ensure functioning properly. I&O – look at next section

This is where you write a narrative note.

0800 arrive at patient home, patient is sleeping, mom voiced he is usually awake, said to let him sleep about 20 more minutes, this SN voiced understanding Patient is receiving internal feed via infinity pump with approx 130 ml remaining. 0820 Initial assessment, patient is in stable condition. Mom will give AM meds as not all medications are on/in EMR. Notified Meredith Green, RN @ 0837. 0910 Patient secure in car safety seat by Dad and Mom in route to Dr appt with Mary Smith, PNP. 0950 Arrive at Children's. Pt tolerated ride well. Mom placed pt in stroller. 1010 Checked in for appointment and mom gave meds with 5ml H20 flush. 1215 Feeding of 225 ml Real Foods Blend formula via GB/Pump @ 170ml/hr. 1250 Patient secured in car safety seat by mom in route to patients home. 1330 Arrived at patient home, patient tolerated ride well. Mom carried pt in to house, placed on sofa to continue feeding. 1350 Feeding completed, flushed with 5ml free H20 via GB. Pt tolerated feeding well. 1415 -1450 PT with Rita from Sage therapy. Focused on holding head up and performed ROM, Patient tolerated well. 1430 LG wet/bm diaper, care complete. No signs of skin break down. 1450 PT, mom placed patient in child recliner, with pillows for support. This SN will continue to monitor. 1540 Patient became irritable while in recliner, Pt moved from recliner to sofa by mom. Made comfortable with pillows. Blood glucose taken per right middle finger stick, tolerated well, pain 0/1/0. BS result 86. 1545 225 ml complete formula via GB/pump @ 170ml/hr. 1600 Patient continues to receive feeding with head elevated at 30 degrees. Left patient in moms care in stable condition. All shift duties complete. End of shift report given to mother.

Make sure you sign off on your assessment and have parent sign.

INTERVENTIONS

This is what it looks like when interventions are completed (it links back to the POC). This is where you MUST sign, enter date

and time you completed the intervention along with any pertinent comments to add. We are not going to do all the

interventions. Only complete the following to learn where and how to chart an intervention. Always pay special attention to

those interventions that are required q shift, on a special day or before/after use.

VERBAL ORDER

You have received a verbal order to add Nystatin (below) to the patient’s MAR. Please add the verbal order into the Kantime ordering section and

chart appropriately in your narrative charting.

Enter in order for:

Now let’s see what your charting looks like. Hit the print icon and print to screen the chart and review it. This is what

insurance companies, parents, physicians, auditors, case managers, supervisors, director and state surveyors will read to

compare your patient care to the written plan of care.

Congratulations! You have successfully charted on your mock pediatric patient. If you have any questions, please contact

your supervisor. Please e-mail your supervisor to let them know that you have completed your mock patient charting

requirements.

Welcome to KidsCare Home Health where we C.A.R.E. about our patients, families and staff.

KEY CHARTING TIPS

1) Chart nurse arrival and departure times with signatures and time in the narrative notes section.

2) Review your plan of care (POC) carefully to make sure the care you are giving aligns with the POC.

3) Review your medication administration record (MAR) and chart all medications administered by you, parent/caregiver or any

medications not given, late or on hold in the comments section of the MAR.

4) If it is in the POC (which is developed by the admitting nurse/case manager) you need to chart per the care plan all interventions

done in the interventions section. This imperative to show the complete picture of the outstanding care that you have provided to

your patient and key to reimbursement of nursing services.

5) In your patients eChart there is a tab called “visit notes” – do not use this for charting any activities or interventions that you do as

this is strictly an internal mechanism (meaning it does not go into the actual chart of the patient). Use your narrative charting space

at the end of your assessment.

6) You must document in the “interventions” sections every shift. Make sure to date and time when the intervention was done.

7) Make sure you date and time every single entry you make.

8) You must document a minimum of every 2 hours.

9) You will document more frequently if needed and per your POC.

10) Charting an outing with a patient: You must chart patient home departure and arrival times, mode of transportation, and who accompanied the patient.