home health form 485

[mewillcare]

any/tips/hepl on how to write a simple,direct to the point 485 :rotfl:

[renerian, BSN, RN]

Short, sweet and focused on deficits.

renerian

[RNLaura]

I was taught to address the reason you are there (acute skilled needs) and not get into chronic problems. If they are diabetic, note that they are "independent with diabetes management" if appropriate. If more than one MD involved in case, note who manages PT/INR for example, on a postop patient. If patient is attending outpatient PT, I note it. I was also taught that a diagnosis must cover all meds. For example, Lexapro is listed, so must a diagnosis for depression.

Hope this helps!

[SWRN84]

I agree with short and to the point. It is not necessary to go into detail for diagnoses that are not pertinent to what you are seeing the patient for. In the agency where I work, we basically use the 485 as our care plan. Anything listed on the care plan must be addressed at each visit until it is no longer an issue, so most of our 485's are very specific as to what needs to be done with each patient. If they don't need GI assessment, then it's not listed on the 485 as an example.

[silverbed0507]

Focus on the acute problems only. Whatever the current problem at the time of admit. Not all of the pt's diagnosis have to be addressed at the care plan. Remember, focus!!!

[RNDP2012]

Hello there

My name is Dunya , I am not a Nurse but I do 485 in the office and I have to add some diseases observations , assessments , teachings and interventions to the 485 . Can someone help me with that?

I will really appreciate if you guys live me some list of diseases assessments and teachings to add in the 485

Thank you

Dunya

[caliotter3]

Hello there

My name is Dunya , I am not a Nurse but I do 485 in the office and I have to add some diseases observations , assessments , teachings and interventions to the 485 . Can someone help me with that?

I will really appreciate if you guys live me some list of diseases assessments and teachings to add in the 485

Thank you

Dunya

Whoever gave you this assignment should be helping you by providing a source for the information. Ask the Director of Patient Care Services or one of the case managers for assistance. You will get it done a lot faster by accessing information available in your office. I would suggest that you start with one 485, work on it, then go to the next 485, by the time you get to the fourth or fifth one, you will already have some of the information from previous plans you have worked on.

[KateRN1]

The 485 is your home health care patient's PLAN OF CARE. It should contain the assessments and interventions that the nurse and/or therapist is expected to perform during the time s/he is caring for the patient. It is not rocket science.

[RNDP2012]

I really appreciate your replies , but what is happening here is different . There is no template to work with or to give to the RNs ,all what I have is what is wrriten in the system and it is very limitted doesnot have all the DX .

if there is any pre-dx assessments and teachings that will really help me thank you

[caliotter3]

You will have to get this information from the nurses who are doing the intakes. They are the ones doing the assessing and teaching. We do not work for that agency and have no idea how your nurses do it there.

[KateRN1]

Perhaps you are not the person who should be creating the 485s. An unlicensed individual should not be creating a 485 whole cloth. Check your agency's policy and procedure manuals for how the plan of care is created and who is responsible. It it NOT just a piece of paper that someone who has never seen the patient dreams up. It is the patient's PHYSICIAN ORDERED PLAN OF CARE developed by a registered nurse in consultation with the physician and then signed as orders by that physician. You should not be giving a 485 to the RNs, they should be giving it to you.

[Isabelle49]

What part of the 485 are you trying to understand how to write?