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CAPC Palliative Care Discussion Forum
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In Reply To: team documentation
Next Reply: Re:Re:team documentation
Next Message: Re:team documentation

Post Re:team documentation
Author: jma
Date: Oct 4, 2007 1:53 pm
I also have the same question. I am the only Palliative Care Nurse in a 350 bed hospital. I chart in the physician progress notes. I keep it simple, so the doctors will read it, writing about only what I address during the visit. I really like charting this way, the doctors all approve, I just want to be sure it is accurate and follows guidlines. Any help and guidance would be appreciated!
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Re:Re:team documentation (by PCoyne on 10/04/2007)
I think that short notes are notes that are read. I suggest that your recs come first, but if you want to track your impact you need to note the issues and scores your impacting perhaps by using ESAS scale.There are no guidelines that I am aware of. Clearly if your billing there are other issues.
Re:Re:team documentation (by sheila_DNP on 10/05/2007)
Each team member charts in the manner of their discipline. Our PC physician charts in the phsycian progress note. My nursing note is electronic in the Progress Notes with the title Palliative Care Nurse Note. I chart using SBAR: situation, background, assessment and recommendations. I include the headings in my charting until everyone becomes familiar with this tool. I see paitents at the request of other staff and therefore don't require a physician order. I also communicate face-to-face with medical residents, discussing patient problems and appropriate treatment options -- including referrals for PC team consults.

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