How specific on 485?

  1. Our agency is working with a QI consultant who is totally gung-ho on the 485 POC, and is having us put down every single intervention we do for a pt -- to the point where "assess lung sounds qv", "assess GU and GI status qv", "assess pain level... qv", "notify MD for HR >100 or <60," "notify MD for respirations >36 or <10 or for new labored respirations," "assess skin integrity," .... etc., for the SN visits.

    you get the idea. Basically, our 485s are now 4-7 pages with every possible goal and intervention for a pt. It's getting SO out of hand, and the nurses are going crazy!!!!!! We've got the disciplines and frequencies... but what else NEEDS to go in there? Do you have all the basic interventions in there at all, do you put them elsewhere, or does your agency just leave that stuff off?

    How specific (or nonspecific) are your 485s? For a pt with >1 diagnosis, for example (like most HH pts are!), what do you put for #21 (Orders for Disciplines and Treatments)?

    Thanks in advance!
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    About bloomicy

    Joined: May '07; Posts: 19


  3. by   annaedRN
    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
    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
  4. by   bloomicy
    Thanks so much - that's really helpful!!!

    To follow up -- for aide service, do you have to specify everything that the aide is to do on the 485?

    And what about who is to do meds (caregiver to fill med box; pt to take pills independently from med box)? Or who assists with which ADLs/IADLs???

    Thanks again!
  5. by   homehealth43130
    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.
  6. by   annaedRN
    To follow up -- for aide service, do you have to specify everything that the aide is to do on the 485?

    And what about who is to do meds (caregiver to fill med box; pt to take pills independently from med box)? Or who assists with which ADLs/IADLs???
    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!)
  7. by   nursemarion
    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.
  8. by   caliotter3
    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.
  9. by   bloomicy
    Thank you all for your help! I suppose it's better to be covered, but sheesh.

    caliotter3, I'm with you in wondering about the MDs. We never get feedback on the 485s -- they just sign, probably 'cause it's just too long and nitpicky to bother going through in detail. It'd be interesting to poll them and see what they think.
    Last edit by bloomicy on Oct 21, '08 : Reason: hit save too quickly
  10. by   Hina2007
    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?
  11. by   nursemarion
    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.
  12. by   Hina2007
    Thank you so much cxg174. You knew exactly why I was asking that question. Now I dont have to wait for a PT eval to write a POC.
  13. by   nursemarion
    There is no regulation on how quickly the turnaround has to be on a 485, as long as it is timely. If you are having a big problem with PT, you can do the eval order, but it is not the optimal solution, and it is a symptom of a problem in the agency. Talk to them in the IDT meetings and see how you can improve the process. Do you have a shortage of therapists? Do you have an agency requirement for turnaround on the 485s? Can it be changed? Sometimes it is just not feasible to hold the 485, but it is the better way to operate. Still, auditors realize that we are all dealing with limited staff. That is why the eval order is used in many agencies.

    What about the managed care cases? Are they better about those? You need paperwork back to request auths. There should be no difference in time frames between the two types of payment sources. Usually if you explain why you need something quickly people are more likely to cooperate. Good luck.
  14. by   HCSllc
    Yikes. I'm a consultant, too and I would lose all my clients if I asked them to write 7 page care plans. The problem with care plans that are too lengthy and too specific is that important stuff gets buried. Furthermore, think of an entire episode. If your visits are weekly you have eight visits max between comprehensive assessments. You are not that good. Sorry. Determine what you want for the patient and how it will be accomplished.

    I had an article published in Homecare Outcomes this week about writing care plans if you have access to that publication.

    Be real careful what you write because if you don't perform all those myriad orders you haven't followed the plan of care which became MD orders when he or she signed the 485.