Oh Topaz, what a great idea!! Why didn't I think of that??
I am sure you meant to say 487 though, as in when doing recerts. Our agency requires the OASIS, a client summary on the 487, detailing why the client needs ongoing care, and the orders, which are formulated from the OASIS and a copy of the previous orders for us to make changes onto, so we don't copy meds etc on the 487, since the new orders will be generated from the changes made on the copy of previous orders. ON the previous orders, we always change the goals, usually change visit frequency, erase disciplines that are finished, change, add, delete meds, etc...
On the 487 we write a systems summary, then write why they need ongoing nursing care and/or HHA or whatever.
Eg. This is how I would write mine off the top of my head for one of my clients....
Client A/A/O MAE apporpo to commands with equal strength. Pain in RLE related to wound, controlled on current pain med regimen
Ambulates using two canes, gait unsteady at times. Hands deformed by rheumatoid arthritis. Client able to perform own ADL's with use of assistive devices, but is unable to reach, or render care to RLE wound. Lives alone, has one caregiver who provides wound care on weekends only.
Dyspneic with ambulating 20 ft, resolves with 10 min rest. Lungs clear, no use of accessory muscles of resp. RR 20
Apical regular s1 s2 aud, no murmurs/rubs. Peripheral pulses easily palpable, +1 edema RLE. Color good, lips and mucosa pinl, cap refill < 3 sec. Skin turgor fair Apical 68 BP 120/60
BS heard in all quads, abd soft, non-tender, LBM 4/30/02 appetite good weight unchaged at 161 lbs
Voiding clear amber, denies s/s UTI, usual quantites
RLE wound 6.2 x 5 x o.5 cm, wound bed red, mod amount serosang drng, peri-wound skin reddened, edemetous, cracked a weeping. Current wound care cleanse wound w NSS, apply fibracol, then tielle dressing, moisture barrier to intact peri-wound skin, q 3 days
Continue SN 1-3 W9 for wound care as client unable to do own wound care due to deformities of hands and limited CG availability.
That's it. I would add HHA to assist in ADL's if he wanted one, but he doesn't want a HHA, though I think he could use one. Oh, forgot to note, I added on this one...
Please note client has been self-treating wound in various ways, such as rubbing legs with a wire brush and applying betadine, or applying olive oil to broken peri-wound skin, and possibly other methods he has not shared w SN, despite warnings not to do so.
...I almost forgot I put that on there. But it sure does take a lot of time! I would love a check list type of summary form. I don't see why we can't just write our usual notes and send a copy of them! If I write all that on my 487 on recert day, I only write in my note "see 487 and OASIS for assessment" and a tiny blurb on teaching and plan for next visit. I used to write it all out, until other nurses at a meeting said they do it this way, and sup's said it was OK, now I will add B-12 inj given to R deltoid if it is something extra like that, or foley chaged, etc...
I have 4 recerts this week, and some days I have 2 recerts and a new in one day, can you stand it, 3 OASIS in one day??? When I have days like that, I usually take them home and work on them the night before, so I don't have so many to do in one day!!!