© 2018 by Helms Home Care

 

1697 N. Highway 16

Denver, NC 28037

704-802-9625 (P)

888-502-5390 (F)
service@helmshomecare.com

clinical documentation

  • If you do not have access to a scanner, there are various free smartphone scanner apps (CamScanner, ScannerApp, TinyScanner, etc.) that allow you to convert a photo into a PDF.

  • If you are unsure what forms are required to document a visit, ask before leaving the home.

    • Some pharmacies require additional forms. 

  • Your RN credentials must be indicated on each visit note (with your printed name and/or signature).

  • Arrival and Departure times should be rounded to the nearest quarter hour (12:00, 12:15, 12:30, 12:45)

    • Do not combine military time with standard time. Use one or the other.

  • All visits should be documented with no less than 30 minutes of visit time.

    • Admission visits should be no less than 1 hour.

  • All visits pay a minimum $50 starting base rate, which compensates you for:

    • Up to 1 hour of your time in the patient’s home (after which, additional visit time is paid at your hourly rate.), and

    • Up to 50 miles or 1 hour of total travel (after which, additional travel is paid at $0.54 per mile or $30 per hour, whichever is greater.).

  • The 5-page admission note is required documentation for patient admission (1st visit).

  • Documentation Includes: Head-to-toe assessment, medication administration (if applicable), checklist for all applicable teaching elements, medication list, and the patient consent form.

  • Patient signature is required on the Education Checklist and the Consent form.

  • Visit time should be no less than 1 hour.

  • If you are infusing the medication you must document the Medication Name & Dose along with Lot Numbers & Expiration dates for each vial.

    • If the patient is self-infusing, medication label information is not necessary

ADMISSION NOTE

  • Documentation applicable for most home infusion therapy visits.

    • Includes, but not limited to PICC line dressing changes, lab draws, PICC line removal, PIV access/de-access, port-a-cath access/de-access, IV-push medication administration, follow-up teaching, PRN assessments, etc.

  • Visit time should be no less than 30 minutes.

  • If you are infusing the medication you must document the Medication Name & Dose along with Lot Numbers & Expiration dates for each vial.

    • If the patient is self-infusing, medication label information is not necessary

STANDARD INFUSION NOTE

  • Required documentation for an IVIG infusion or any infusion in which the medication is administered over 1 hour or more.

    • Titration record is needed in addition to the Admission Note, when applicable.

    • Titration record is not needed for patients who are self-infusing.

  • Titration record must be completed with baseline vitals, then vitals at 15, 30, 45 and 60 minutes, each hour thereafter, and then 5-10 minutes post infusion. 

  • If you are infusing the medication you must document the Medication Name & Dose along with Lot Numbers & Expiration dates for each vial.

    • If the patient is self-infusing, medication label information is not necessary

TITRATION NOTE