Charting Tips

Give an Honest report. If you don’t think the visit went well, say so. Not all visits may be ‘warm and fuzzy’ ones. That’s okay! Report your visit accurately.
Example: “Patient did not want to talk to me today, he turned and faced the wall.”
What were your Observations? Report what you observed in your visit.
Example: Patient was sad. “Patient said, “I miss my son” and cried multiple times during the visit.”
Write with hospice Staff team members in mind. What about your visit might be interesting to the RN Case  Manager, Social Worker, or Chaplain?
Examples: “Patient said he no longer has a desire to eat.” “Patient said that she misses her grandchildren.” “We prayed together during our visit.”
Include patient Presentation, how the patient appeared to you.
Example: “Patient presented alert, was talkative, and said that they were happy to see me.”
Describe your Interaction with the patient.
Example: “During our visit we watched television, read poetry. I held patient’s hand for much of the visit. We shared a lot of laughter today.”
How did you Communicate with the patient?
Examples: “Patient and I talked about gardening, his favorite book, and fishing.” “Patient was non—verbal today.  I held patient’s hand and spoke in a way that did not require a reply. Patient responded to my touch by squeezing my hand.”
Describe the Environment during your visit.
Example in a facility visit: “Patient was in bed. Window blinds were open and room was bright with sunshine. Roommates were noisy during our visit.”
Example in a home visit: “Patient was seated in his living room with the television on at my arrival. House smelled like cigarette smoke.”       
Kindly submitted by Suzan, Mission Hospice Volunteer