Admits and Resumptions without medical documentation
- 1Jun 27, '13 by Isabelle49Just curious, are you frequently required to Admit or Resume care post hospital without medical information? How do you do that? I've been in home health 10+ year and I'm still not sure how this works. We used to get a H&P or D/C Summary that would tell the nurse most of what she needed to set up a plan of care. Now we get nothing or maybe a few diagnoses that someone in the office entered into the system (who knows where they get the information from, because it's not on paper and not available for the clinician to review prior to or during the patient visit.
How can an angioplasty be a diagnosis for hospitalization in the case of a ROC?
Just interested on your thoughts on this. I am 99% retired as an RN and ready to be 100% retired, because I do not have the psychic ability that others have!
- 1Jun 28, '13 by AMN74First of all, as you know you can't do an admit, roc or recert without an MD order. Often times we get an order that says something like Home Health to eval and treat for patient needs.. Duhhhh So if the patient is coming out of the hospital, I always ask them to have their hospital discharge sheet ready when I am coming to make my visit because at least I can reconsile medications and check any orders that may be written there. Obviously sometimes I go out s/p angioplasty or whatever and find a wound...Then my agency has blanket orders to do wet to dry ns dressing until we can get md order. I will put a wet to dry on and then call md office and ask for wound care orders, or suggest wound care orders and ask if they are ok with it. If the patient has a new or an exacerbated disease process obviously that is what I will focus on for teaching and Plan of care. So even without proper paperwork from the hospital or a discharge planner I try to make it work with what I have. Hope this helps...
- 0Jun 28, '13 by KelRN215, BSN, RNI am occasionally in this position when doing same day admissions in the evening or weekend admissions. We rarely get the paperwork on time and are sometimes flying by the seat of our pants. I ask the patient/family for the discharge paperwork given to them by the hospital but they don't always have everything I need.