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Discussion

Ensuring all orders are on 485...

How would you handle the documentation of this?

RN admits client on Saturday, client wants flu shot. The RN calls the MD on Monday and gets the order for the vaccine and supplies.

Do you include the order for the nurse to administer the vaccine, the supplies, and the medication on the 485? Or, do you leave it off and add a supplemental/ interim order because you didn't really have this order at SOC?

I'm wanting to include this information in the 485, but the RN performing the SOC does not think it should be done. I look at it in the same light as PT evals and their inclusion on the 485 if done within a certain time frame.

Are there written guidelines to time frames for inclusion on the 485?

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    We include everything we can on the 485. additional orders=additional paperwork piled on a doctor's desk somewhere awaiting signature.

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    How does your agency build 485s? I work as a Case Manager in Home Health and I do almost all of the 485s... one nurse I work with is a field Case Manager and does his own, but any other nurses' patients are mine to manage. In the situation you describe, I would include the order on the 485 because I wouldn't be doing it until Monday anyway. And I agree with the PP that the more orders you send to the doc, the harder they are to keep track of.

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