I have worked for the same HH agency (hospital based) for 2 years now. In that time we have had 6 directors... we recently had a survey that apparently didn't go like they thought it should. One of the issues that was brought up was our 485's. Now the director is telling us that we have to teach EVERYTHING on the 485 with EVERY visit. Prior to this our 485 would say something like
Teach: Disease process - Diabetes (foot care, self assessment, when to call, diet...)
so then our computer based charting system would give you a drop down with the things in () to select from to teach a different one each visit. She gave me back 3 485s today to change. Some things were duplicated because of the system and did need to be taken out; but she also told me I can't put "standard precautions" in because there is no definition??? Excuse me? That's why it's STANDARD!!
I learn more and more every day that most of what she tells us is not right but I just wondered on this issue how everyone else does it? TIA for any input.