Are you are tired, frustrated and approaching “Burn-Out” because you have so much documentation to finish at home? Does it feel like you don’t have a life outside of work? Well, I know exactly how you feel because I felt the same way and I almost gave up. I did documentation at night until I couldn’t think straight and started again early the next morning or even sometimes a couple of days later. Then I found a way to Get My Life Back!
Tips for Completing Documentation in the Home
Since I have learned to complete documentation in the home several
co-workers have asked for tips on how to do it. As a new Preceptor I want to instill the importance and benefits of completing documentation in the home as they are getting started with Encompass. I believe this will lead to happier co-workers that stay with us longer. If you have been with Encompass for some time my hope is that this will also help you to reduce your documentation stresses.
You may want to bookmark this page because I will update it occasionally with new ways to speed up your documentation in the home. I met a couple other clinicians, while at the Preceptor Workshop, who also complete their documentation in the home, so we know it is possible. I am open to any suggestions or additional tips that can help our co-workers get their lives back.
When you have some free time you can read my testimony How I Got My Life Back. But first, let’s get started with the important matter of learning some tips to speed up your documentation.
“Don’t just make a visit.
Make a difference.”
GROW INTO IT: Set a goal to complete one document in the home, then two, then a full day. Grow into it. It is a lofty goal and doing it will get easier as you do it. I DO KNOW that it is possible and that it is well worth the effort.
MINDSET: It’s a Mindset thing. We can either enter a home with the Mindset of Trying to complete the documentation or we can enter believing that “THIS IS WHAT I DO. THIS IS WHO I AM. I complete the documentation, in the home, because it is best for the patient and best for me.”
HOW TO SPEED UP YOUR DOCUMENTATION: Each tip you apply can shave off several seconds or even minutes. As you add them together you end up with a better chance of finishing in the home.
FOUNDATIONS WORKSHOP: If you have not been to the “Foundations Workshop” at the Home Office, in Dallas, Texas, make it a point to attend. That is where I received my inspiration to set high goals: Wildly Important goals. All the presenters were positive, encouraging and inspiring. I call it a “Red Carpet” experience.
REVIEW ORDERS AND H&P: Look over the paperwork including history and physical and orders the day before so you’re very familiar with the patient before you call them for the appointment. This makes us sound well-informed and more professional. I remember once asking a patient what they were in the hospital for and she said, “Don’t you know? Didn’t you read my chart?” Ouch. Trust me. That no longer happens!
TEAM EVALUATIONS: Whenever possible, do team evaluations or Starts Of Care. This would include an RN doing the start of care and a therapist (PT, OT or ST) doing an initial evaluation or a home safety evaluation during the same visit. The nurse and the therapist are less stressed and able to complete much if not all of the documentation while in the home and the patient gets more attention and gets their start completed in a smaller time frame. A win, win, win situation. I asked Robin Chesterman, our Branch Manager if I could do a SOC with her. She did the SOC and I did the PT Evaluation. Because we were able flip flop back and forth or take turns our stress levels were reduced and it was a very rewarding experience. Diane, our amazing scheduler, suggested that when a PT does the SOC the OT could do an eval or home safety eval at the same time. That would help both of them to complete the documentation in the home. (HELP: If anyone has ideas on how we can get initial orders with Two Disciplines included it would make this possible on a consistent basis.)
FOCUS ON WHY WE ARE THERE: Whenever we walk into a patient’s home we need to know why we are there. What specific SKILLED SERVICES are to be used and how do they SUPPORT MEDICAL NECESSITY? This will help us stay focused and complete the notes in a more timely manner.
SET THE STAGE for FINISHING IN THE HOME: I set the stage for finishing the document in the home by telling the patient “It’s important for me to get the documentation done while I’m still here with you and here’s why:
1. “While I’m still here with you I have a better memory than I will have at 10:00 tonight. LOL.
2. You can help ensure that I write everything down correctly (while I am dictating) so the doctor and all the other clinicians will have the most accurate information about our visit.
3. “When I do this documentation/paperwork here with you we can ask each other questions. This helps me to understand how to best help you and it allows you to get all your questions answered.
4. By getting the documentation done in the home the doctor and the other clinicians will have access to it quicker so that will make your next doctor’s visit or nurse or therapist visit more informed. We want to treat you in the best way possible. Thank you so much for understanding and for helping me with this.”
EDUCATE PATIENT ABOUT THE DEVICE: During my first visit I educate the patient that there are three levels of doing documentation on my device.
Level 1 is paying undivided attention to the patient when I first get there to find out what’s on their mind and what I can do to help- especially if they are emotionally distraught or concerned about something. During these times I don’t even want to touch my device. They appreciate undivided attention at times like that even if it’s only for a few minutes. They deserve it.
Level 2 is during more informal conversation. I tell them that I will listen to them but also make some entries on my device while looking down occasionally and looking up occasionally as we continue to talk. They usually do not mind as long as they do not feel ignored. Establish eye contact frequently.
Level 3 is where I say “Hold that thought. You’re way ahead of me.” LOL. Let me catch up with you and talk into this device and it’ll convert my voice to text. Now, as I summarize what you just told me listen carefully because you can let me know if I’m saying it the way you told me.” They enjoy being involved.
USE VOICE TO TEXT: Learn to use Voice to text (only works when you have a good cell phone signal) It allows you to make very rapid entries and the patients often enjoy listening and keeping it accurate. They like being involved. (NOTE: Be sure to read it over because sometimes it misunderstands what you say. If you have used voice to text on your phone or device you will relate to what I am saying.)
SYNC BEFORE YOU LEAVE TOWN: Be sure to ACCEPT patients and sync before you drive to outlying areas with no cell coverage. This will keep you from having to drive back to where you can sync before you start your visit. This reduces frustration which allows you to think better during the visit.
ADDRESSING INTERVENTIONS: For a long time I tried to address ALL of the Interventions during each visit. I just learned, at the Documentation Class, that we can focus on just 2-3 of them and not address them all. This can save us a little time. REMEMBER THIS: Medicare requires that Every Intervention must have a mention of the patient’s Response: Return demonstration, Physiological Responses, or Verbal Response from Patient or Caregiver. It is OK to use the drop-down suggestions but it’s wise to edit them or add to them to make it patient specific. (NOTE) For therapists this section is where the PointCare system currently draws from for Objective portion of your SOAP note. It is here where we need to use our skilled terminology while being very specific of what we do for the patient.
THERAPY GOAL/STSTUS GRID: We do not need to address every goal on each visit. The expectation is to address 2 Objective tests per week.
GET CREDIT FOR COMPLETING THE DOCUMENTATION IN THE HOME: If you are trying to get your in-home documentation metrics high enough to apply for the Certified Preceptor Program, remember this: If you complete the visit in the home and before you leave the house you go back into the visit (Resume) to check something even for one second the system no longer considers that you finished that visit in the home. Sometimes the patient will ask: “When are you coming back?” It is best to check the calendar before you sign out but when you forget you can access it by going into medical records and looking at their calendar without negatively impacting your metrics.
TRAIN YOUR DEVICE: Teach your device commonly used phrases. You will notice that when you get a new device it is “Dumb” but the good news is that it learns as you use it. As you make common entries, like: “This is a 30-day reassessment and the patient has improved in the following areas:” it learns and remembers. After the device learns all you have to do is press on “this” and keep pressing as it spells out each word. It is very quick and is a way to work fast even when you are out of signal range. Also, after the device learns the names of your LPNs or Assistants all you have to do is type the first letter of their name and it suggests the rest. Very quick.
AVOID EXTRA DOCUMENTATION: Avoid extra and unnecessary duplicate documentation. This is covered in great length at the Defensible Documentation class. Copying and Pasting is referred, by Medicare Auditors, as “Cloning” and is frowned upon.
REVIEW DROP DOWNS: Become familiar with the drop-downs so you can navigate through them more quickly. This will naturally happen with time. As you become more familiar you will move faster. Be patient with yourself.
STAY SHARP: Eat right and stay hydrated. Did you know that 1-2% reduction in the brain hydration can mean problems concentrating and thinking. Learn more about how dehydration is an enemy of optimal performance.
And take the supplements that work best for you. I take one that keeps me alert and focused. If we are going to complete the documentation in the home we have to STAY SHARP and focused. We need to operate at OPTIMAL PERFORMANCE.
Specific to Starts of Care:
GATHER THE SUPPLIES: Remember to bring: a scale, disposable tape measure, calendar, refrigerator magnet card, planning calendar, and the Patient Handbook.
USE A CHEAT SHEET: When I first started doing SOC’s I put together a Cheat sheet to help me ask all the right questions in a timely manner. You may have one available or you can use My Admit Cheat Sheet If you use my sheet please feel free to modify it an make it your own. Admit Cheat sheet
MEDICATION ENTRY in HALF THE TIME: This only works when the spouse or caregiver does the medication management and sets up the meds for the patient. Have spouse, caregiver or patient read the med labels, MG, number of tablets and frequency to you as you enter the meds. I discovered this last week and tried it again yesterday and it enabled me to enter the meds in a fraction of the time. Another benefit was it involved the caregiver or patient as we discussed each medication as we went along.
Device Shortcuts to Save you Time
Accept ALL Visits: Instead of accepting one visit at a time Long Hold the Day of the Week and you will be able to accept all he visits for that day.
Launch Google Map to View Day’s Visits: Long Hold the day of the week and you will be able to see all you visits plotted out on the map.
View Attachments: While in a patient’s Medical Records, Tap Attachments. Then Long Hold on the one you want and it will load.
See History of current status over time: While therapists are in the Goal/Status Grid they can Long Hold on the metric (like TUG or Gait) and it will allow you to see the history. It is faster than going to Medical Records and Therapy History.
Medical Records Starting Points: When you look at medical records you will see over 30 selections. Since this looks a little overwhelming here are a few very important ones that are most commonly used. Feel free to become acquainted with the others as you can:
– Attachments: View H&P and orders
– Calendar: See who is scheduled to see the patient and when. Patients like to know this before you leave the visit.
– Coordination Notes: Displays Case Conference Notes, Narratives and Clinical Notes
– Demographics: “Personal” gives DOB which you will want to have handy whenever you call a doctor’s office. “Address” gives street address and phone number. “Payor Source” will tell you if they have a co-pay which they must be informed about before you have them sign page two of the SOC forms.
– SOAP Notes: Displays therapy SOAP notes by clinician. Tap on blue code and read the note.
– Therapy History: This allows you to look at Therapy Goals/Status History. Click on a blue goal and it will display a list of Goals. Click on a specific goal and it will show you a date by date history of how they scored on that goal which is a good way to show them their progress.
This is a work in progress. Be sure to check back frequently.