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!
Oct 21, '08
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