I've been doing home health for a year now, but I don't feel that I was trained well. I was just wondering, on a routine visit with a patient, what is your routine for assessment? I don't feel that I really have a routine and sometimes I miss checking something and don't realize it until later when I'm doing the paperwork.
So on a regular SN visit, what is your basic routine? And how does it differ from when you are doing an admission or recert assessment? I know it seems basic, but sometimes I feel like I'm "losing it" when it comes to the basics.
Aug 11, '10
At any visit, regardless if it is an OASIS timepoint or not, you should be doing a full head to toe physical assessment. Depending on what is going on with the patient, I try to organize and focus my assessment in a way that makes sense for the patient. For example, if the patient is complaining about increased shortness of breath or edema, I assess those things first, and then follow-up with a full head to toe assessment. As far as the physical assessment, there should not be much difference between a routine visit and an OASIS assessment. With the OASIS assessment, I have the patient do the more formal "OASIS walk" in order to answer the functional M-items (sitting down and getting off the toilet, stepping in and out of the bath tub, etc). I also assess their vision (have them read a med bottle) and hearing a bit more formally, although these are also a requirement of a basic physical assessment and technically would be assessed at every visit. The OASIS assessment also requires an in-depth assessment of the patient's social and environmental living situation. These issues could also warrant follow-up on a routine visit. I hope this helps in some way!