H&P

[jmn126]

Do you all get a h&p on a new referral? If not do you use your clinical knowledge when determining diagnosis, such as patient on insulin-- you can assume IDDM,,,on lisinopril you can assume HTN. I know having the h&p in optiimal but not always available. I read in the OASIS manual that to answer M 1020 use your interview with the patient. Justbwondering how you all do it.

[SHGR, MSN, RN, CNS]

?? Insulin doesn't mean IDDM, it means a diabetic patient that uses insulin (may or may not be dependent on it- i.e., a person with T1DM will go into DKA if they don't have insulin, whereas a person with T2DM will not, and can live with very high BG for a long time). Also, lisinopril or another ACEI is used as a kidney protective agent in patients with DM, not necessarily that they have to have HTN to be on it.

[jmn126]

i was intending the question to be used as a generallity question, i guess i should of worded it differently. for that i apologize,,,,my question is what do you do if you do not get and can't get a H&P

[nursynurseRN]

You are right sometimes my agency gives me a h&p and sometimes they don't. I try and get all of their medical history using their meds and interviewing them.

[84RN]

Do you all get a h&p on a new referral? If not do you use your clinical knowledge when determining diagnosis, such as patient on insulin-- you can assume IDDM,,,on lisinopril you can assume HTN. I know having the h&p in optiimal but not always available. I read in the OASIS manual that to answer M 1020 use your interview with the patient. Justbwondering how you all do it.

We're encouraged to ask the physician's office to fax an h&p if possible, when we call to let them know we've done the SOC. If not, then you can always ask "Are there any comorbidities that we should know about when making the plan of care?"

Sometimes a family member will be in contact with the agency, or the caregiver, and can give you some medical history info.

It can be very challenging, that's for sure.