Return-Path: <nifl-health@literacy.nifl.gov> Received: from literacy (localhost [127.0.0.1]) by literacy.nifl.gov (8.9.3/8.9.0.Beta5/980425bjb) with SMTP id RAA06462; Wed, 14 Jun 2000 17:21:22 -0400 (EDT) Date: Wed, 14 Jun 2000 17:21:22 -0400 (EDT) Message-Id: <200006142115.RAA06241@literacy.nifl.gov> Errors-To: listowner@literacy.nifl.gov Reply-To: nifl-health@literacy.nifl.gov Originator: nifl-health@literacy.nifl.gov Sender: nifl-health@literacy.nifl.gov Precedence: bulk From: G4DNeri@aol.com To: Multiple recipients of list <nifl-health@literacy.nifl.gov> Subject: [NIFL-HEALTH:2438] Clinical Documentation Form X-Listprocessor-Version: 6.0c -- ListProcessor by Anastasios Kotsikonas Content-Transfer-Encoding: 7bit Content-Type: text/plain; charset="US-ASCII" X-Mailer: Unknown Content-Transfer-Encoding: 7bit Content-Type: text/plain; charset=US-ASCII Status: OR Hello, All - I am trying to redesign the encounter form our grant-funded program uses to document encounters with our clients and would appreciate your suggestions and insights, and samples if you're willing to share. I am in a unique role that combines the Community Health Clinical Nurse Specialist role with that of the Family Nurse Practitioner. For those of you not familiar with the many possible advanced practice nursing roles, that means (broadly) that I work at the individual and family level and can do the diagnosis and treatment of disease piece, as well as health education, case management, disease prevention/screening, etc. That's the NP role. But I also can look at the population/community/aggregate level and assess, diagnose, plan, intervene and evaluate there as well. That's from the Community Health side of things. It's a very exciting and challenging job! At any rate, the encounter form I "inherited" when I took this job about 10 months ago is primarily a template for writing a standard SOAP note, with blanks for recording vital signs and the like too. The SOAP note format (Subjective, Objective, Assessment/Analysis, and Plan) is primarily useful at the level of disease diagnosis and intervention, which is a very small part of what I do. Aside from women's health exams, for which I use an entirely different checklist style form, I am doing lots of health education and case management, in clients' homes, in my office, and much of the time at "health depots"...kind of a free clinic without walls. At the health depots I often see some clients every month over a long period of time, doing a kind of "interim chronic care management", with lots of health education and self-care/self-management training...helping nudge people closer to the action stage of behavior change over time (ref. to Prochaska's Stages of Change model). So....I am thinking of a form that I can complete very quickly, where I don't have to write out a lot of prose, since I see many of these folks every month, or at least several times a year. A checklist format as a base, with some room to jot down individual comments....something that has a place to note where they are with regard to goals for behavior change and which stage of change they are at at that visit. It would also be nice to focus on what strengths the client and family bring to the situation as well. Anyone out there have a form (1 page, preferably) they use for wellness visits, with a focus on health education, screenings, case management, chronic care mgm't., etc.?? Oh...we use the U.S. Gov't's "Put Prevention Into Practice" guidelines for age and gender specific screenings, and have a flow sheet to keep track of when those are done from year to year. That's on the left side of the chart, and the encounter forms, on which we document each visit, are on the right side of the chart. Let me know if you have any thoughts about this, or samples! If anyone is willing to share a form they already use, they can fax it to me at the number below, or I can send my snail mail address, if it can't be attached to e-mail. Thanks in advance, Donna ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Donna Bain Neri, MSN, RN, FNP-C Family and Community Health Nurse Practitioner Healing Touch Practitioner ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Clinical Consultant & Health Educator Rural Health Outreach Program Nelson County, Virginia, USA W: 804.263.4858 Fax: 804.263.4160 E-Mail: g4dneri@aol.com
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