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Should a nurse’s notes include intent to follow up with patients?

Dear Nancy,

In the narrative section of my nurses notes, is it a good or bad idea to write, “Will follow up with patient during next scheduled home visit and as needed?” Depending if I am out sick or my agency sends me to cover a different county, sometimes I am not the nurse who does the next follow-up visit. Although it shows my intention to follow up, some nurses have told me it is not a good idea to write that.

Isabel

 

Dear Isabel,

Generally, a note to follow up with a patient in the home care setting is a good idea. Such documentation indicates a need to do so, whether at the next scheduled visit or as needed. However, since it sounds as though you don’t always have the same patients to see on a regular visit, you might want to make the notation but not for you alone.

As an example, documenting “Recommend follow-up with patient during next scheduled home visit or as needed” tells any reader — you or one of your nurse colleagues — that your assessment for the follow-up was identified and recorded. It would then be up to you, or one of your colleagues, to ensure the follow-up was done.

This assumes the nurse who does the next visit (if you don’t) reads your note before visiting the patient. This is always a good idea, whether the patient is one you see regularly or one who is seen by another nurse. Neither one of you should miss what needs to be done when a home visit is carried out.

Cordially,
Nancy

By | 2015-09-29T13:38:26-04:00 September 30th, 2015|Categories: Nursing careers and jobs|0 Comments

About the Author:

Nancy J. Brent, MS, JD, RN
Our legal information columnist Nancy J. Brent, MS, JD, RN, received her Juris Doctor from Loyola University Chicago School of Law and concentrates her solo law practice in health law and legal representation, consultation and education for healthcare professionals, school of nursing faculty and healthcare delivery facilities. Brent has conducted many seminars on legal issues in nursing and healthcare delivery across the country and has published extensively in the area of law and nursing practice. She brings more than 30 years of experience to her role of legal information columnist. Her posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state. Visit The American Association of Nurse Attorneys website to search its attorney referral database by state.

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