How specific on 485?

Yikes!!!
I would NOT be liking that! I can't see how being that specific would benefit anyone! Actually it would be probably make it harder to maintain compliance with MD orders then. Here is an example of a 485 order/goals etc from a total knee patient I just admitted 1-2 weeks ago. I usually break my orders out into Assess/Perform/Teach because I feel it organizes it and makes it easier to read....maybe I am a little OCD too! Hope this helps!

SN visits 1w1 2w1 1w1

ASSESS: Assess cardiopulmonary status (vs, heart and lung sounds), medication administration, safety, nutrition, hydration, elimination, general skin condition, patient/caregiver's knowledge of disease process/management. Assess for s/s of bleeding. Assess for s/s DVT. Assess R knee incision for s/s infection.

PERFORM: Perform O2 sat monitoring PRN for dyspnea; report sats < 88% to MD. Perform venipuncture every Mon & Thurs for PT. Lab results to Dr ____.

TEACH: Teach patient/caregiver medication schedule, dose and side effects, disease process/management, nutritional/hydration requirements, safety, emergency response plan, pain control techniques, and when to notify physician/nurse/911. Teach patient/caregiver anticoagulant precautions. Teach patient/caregiver foods that should be avoided with use of Coumadin. Teach s/s of bleeding. Teach s/s infection.

PT -eval/treat

Goals/Rehabilitation Potential/Discharge Plans
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Patient/Caregiver will understand/comply with instructions/teaching by 10/6/08
Patient's PT/INR levels will remain stable throughout Coumadin therapy
Patient's pain will be adequately controlled by 10/10/08.
Patient's R knee incision will heal with complication by 10/21/08
Stabilization of health as evidenced by stable V/S and management of meds throughout cert period

Rehab potential is good

D/ C when care no longer needed or max home rehab potential has been met

Just another take on this: We have been sited by our State surveyors in the past for being too general and doing things that were not on the 485, we have also been sited for not doing everything that was on the 485. We tend to go into a little more detail - especially with teaching - and qualify it by stating as patient/caregiver able to learn.

I write for example - HHA visits 3w4 Aide: Assist with bathing and ADLs/IADLs each visit. Light housekeeping PRN. Then we make a separate HHA care plan that the HHA scheduler makes copies of for all involved with HHA and for patient's home folder. That careplan is in patient chart and is specific to orders for tub bath/shower/bed bath, shampoo, lotion, emptying urinal/BSC, etc.

If there is anything in particular, like meds, I will make specific in orders - teach caregiver to fill/manage medication compliance box. HHA are only allowed to remind to give medications and apply OTC ointments (Neosporin).

At each visit, we go through and follow up on all the systems ( GI, resp, cardiac, endocrine, musculoskeletal, etc) and document -we use computer charting -what we assessed, provided and taught. So far it has satisfied the surveyors (hopefully that won't change!)

In my experience all surveyors are different. In general, if it is a standard policy to do something every visit- such as vitals, that does not need to be there. If you put things on there to sound good, you will get caught being out of compliance eventually. They know when you are just giving lip service. I would focus on why you are seeing patient. Interventions should be focused on these diagnosis. A nurse who knows nothing abot the patient should be able to pick up a 485 and know what to do for that patient. To me that is the gold standard, going back to the old days when the 485 was the most important thing.

How interesting that you are having this problem. Seven page long 485's are the norm for one of my present employers also. The case mgr opened a case and didn't do a complete listing of the meds and asked me to write up the orders for the MD. Then, after I did the work, everything got edited around and rewritten with the mgr's signature. Uh, the mgr could have done it the first time around. After all, that's this person's job. But I sense a critical nature at work here and I'm not talking about how I view it. Everything that I take the initiative to do and send forward has to be "edited". The 485's are so cumbersome and hard to work with, that I have made a working copy for myself and highlighted what is necessary. I go through the trouble of making certain my "working" copy isn't in the book when I know the supervisor will be doing a visit. I don't have time to go through three and four repetitions of telling licensed nurses that they need to do vital signs and report changes. I already know that. I've wondered what the MD thinks when they get these monstrosities to sign.

Is it Ok just to write PT to treat and eval on POC? I thought this has to be very specific too with modalities used and the duration/frequency?

If you are just doing an eval- 1 x week x 1 then writing orders later you can be pretty general about it but you have to say what the eval is for such as safety, need for equipment, etc. But you need specific orders and goals so it is easier to put them on the 485 to begin with. Usually you can get what you need from the PT eval, or even a verbal report from the therapist if they are slow getting in there and geting notes back.