I'm an experienced RN but new to home health nursing; especially skilled nursing documentation requirement, OASIS, 60 day summary. I was hoping those of you with experience could be of assistance to me.
I work for a new, small agency that is getting ready for its first initial state survey. The agency is owned by an RN but her home health experience is limited; therefore my orientation was somewhat challenging. But she is a good friend and I'm trying to help her out.
I've done extensive research on OASIS, read the user manual on CMS website, view an online course but I'm still confused about some parts of it. I'm having problems with the part where you have to write a narrative as I don't know what to write.
For example:
(1) Endocrine/hematology Disease Management Problems(explain)- what do I write
(2)Pain
How does the pain interfere/impact their functional/activity level(explain) what do I write
(3)Cardiopulmonary Disease Management Problems(explain)- what do I write
(4) Fall risk assessment
The patient is a high risk for fall but then the question ask: plan/comment
Do I document fall risk interventions or what do i write?
(5) Living arrangement/supportive assistance
If a patient lives alone, but has a paid caregiver who assists with household chores. Does that counts as a primary caregiver?
(6) what has to be included in a 60day summary of care? A sample would be greatly appreciated.
(7) Skilled nursing note- I was told it has to justify why home care is being provided and speak to the plan of care and contain certain phrases or words. If someone has a sample they want to share.
(8) Those of you that have been through the survey process, what should we expect?
