Let's clarify nursing documentation needs for home infusion therapy providers

This overview can help clarify nursing documentation for home infusion therapy providers. Documentation should include the following components.

• An evaluation of the patient, including:
• The diagnosis and reason for therapy with each visit
• A basic assessment of the patient, including orientation, breathing, color, complaints or anything related to diagnosis. For example, if a patient needs home infusion for an infected wound, there should be information about the wound and the dressing. If the nurse doesn’t change the dressing, he or she should not simply state that the wound has a nonremovable dressing or the wound clinic is performing wound care. If there is no dressing change, documentation, at a minimum, should include a detailed assessment of the dressing and surrounding area
• Questions about any side effects to the drug or how they were feeling after the last dose
• The visit’s start and end time
• The infusion’s start and end time
• The therapy the registered nurse administered during the visit
• Notes about teaching the patient or caregiver, assessment of patient’s or caregiver’s technique for self administration
• The patient’s response to infusion given
• Any changes in treatment
• Date, signature and credentials of the registered nurse