Patient Documentation and SOAP

Dear Nurse Michele . . .

Dear Michele:
My friend was a retired LVN. She recently returned back to work. She does in-home visits for MedicAid patients. She is struggling with writing her notes.  She was told that MedicAid wants simple notes so that they don’t have to read every line. Do you have any suggestions? She’s been told that her notes are too in-depth and she is becoming depressed. Please help.

Answer:
There may be different requirements for documentation in different states. However,  just the facts regarding the primary patient issues, V/S, safety, and support are usually the priority. Her agency should have an outline for her to use and follow. Here are two websites that may help right away:

http://www.ehow.com/how_7231052_write-progress-notes-soap-format.html
http://www.fadavis.com/online_store/catalog/catalog_detail.cfm?publication_id=2427

These links are for SOAP notes and a textbook. (SOAP: Subjective data; Objective data; Assessment data; Plan.) There may be examples of home care notes on the internet, or your mom should ask her agency for examples they would like her to follow. They have an obligation to train their employees. She may want to ask another home care nurse to let her tag along and read their notes – without asking her employer for extra money.  Let me know if this helps at all.

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About Michele G. Kunz

I am a nursing educator and AHA Certified Instructor and I specialize in providing AHA Certification classes in ACLS, BLS, and PALS to healthcare professionals and students. I am also a certified six-sigma green belt (CSSGB).
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