Writing orders

[welch07]

Hi I am new to HH. My back ground is med surg in a hosp and have been a rn for well over 5 yrs. my question is writing home health doctors orders is a little different than what I do in te hosp. Any one have any advice about how etc? Thank you

[nursegwen1]

That is illegal. Make copies of your orders.

[blueshift124]

The 485 is a matter of filling in the blanks. Most of it is fairly obvious, but you want to make sure you put frequency and duration in there under the "Orders for Discipline and Treatments" section (Section 21). For example, RN for skilled nursing visit and assessment q 2 weeks. If the patient has an aide you also want to put that in (ex. HHA 5 days x 4 hours). Also make sure you put in a line about discharge planning in that section.

[welch07]

Thank u blueshift124. The more hints I get the better. I am getting the hang of it. It is just gonna take some time. Still no orientation but that's ok

[paulinejoyRN]

Writing orders is different for each case, but the bottomline is that you take orders from the MD, not mom, and need the paper trail of orders to cover your license.

For admissions, I always call the MD and let them know if I found anything different. Then I write a sup order, "During admission visit, updates to medication profile were found..." then send to PCP for signature.

For recerts, I always write orders, "During recertification visit, updates to plan of care found:" then list the med changes you found during your med rec, changes to the 485 orders (like family only uses warm soapy water to clean the GT), etc.

Just make sure that you let the PCP know that these changes will be coming, and that he should call you if there is anything he would like to modify or clarify. Then write the order, because at least you called the PCP to let him know.