home health form 485

RNDP2012 · Oct 15, 2011

Thank you Isabelle

how I do the 485 is by writing the observations and assessments then after I done with them I will write the teachings and interventions.

I was trained many ways to do it and I feel myself very confused now. I go by DX now like for HTN or DM I will search for an assess or teach for these DX and put them there. what is happenning is when there is a DX that the System doesnot have a description for it then I am stuck there. I am always looking for some template to copy and paste what is there and work with it. I hope you get my point. For example patient who has CKD I don't have a DX for it and I am not a nurse so how I should write something I don't know about it ?

Isabelle49 · Oct 15, 2011

Thank you Isabelle
how I do the 485 is by writing the observations and assessments then after I done with them I will write the teachings and interventions.
I was trained many ways to do it and I feel myself very confused now. I go by DX now like for HTN or DM I will search for an assess or teach for these DX and put them there. what is happenning is when there is a DX that the System doesnot have a description for it then I am stuck there. I am always looking for some template to copy and paste what is there and work with it. I hope you get my point. For example patient who has CKD I don't have a DX for it and I am not a nurse so how I should write something I don't know about it ?

The assessing clinician should be giving you all of the information to create the 485. Most if not all of this information comes from the OASIS that is necessary. When the information on the OASIS is entered into a system, the appropriate information is carried over to the 485. In other words, these programs communicate with each other. The assessing clinician should give you the diagnoses codes, or someone in your office who is qualified and knowledgeable about the codes should look them up. Appropriate coding and order of diagnoses can impact payment for services.

HealthyNurse · Oct 16, 2011

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

Hi Dunya- It's not that I don't want to help you, but your post is very concerning to me. I work as a state surveyor of home care and hospice agencies and it is very inappropriate to have an unlicensed staff member formulate the 485. The 485 is the plan of care that is developed by the nurse or qualified therapist in collaboration with the physician. Even if it were a nurse in your office that was developing the 485, that would still be inappropriate. The 485 needs to be developed by the nurse that has actually seen and assessed the patient, after discussing the specifics with the physician. Every patient and their needs are different, so the 485 needs to be individualized. A 485 for one patient with CHF should not be the same as another patient with CHF.

I would be very wary of what your employer is asking you to do. This is certainly against regulatory requirements.

caliotter3 · Oct 16, 2011

Hi Dunya- It's not that I don't want to help you, but your post is very concerning to me. I work as a state surveyor of home care and hospice agencies and it is very inappropriate to have an unlicensed staff member formulate the 485. The 485 is the plan of care that is developed by the nurse or qualified therapist in collaboration with the physician. Even if it were a nurse in your office that was developing the 485, that would still be inappropriate. The 485 needs to be developed by the nurse that has actually seen and assessed the patient, after discussing the specifics with the physician. Every patient and their needs are different, so the 485 needs to be individualized. A 485 for one patient with CHF should not be the same as another patient with CHF.
I would be very wary of what your employer is asking you to do. This is certainly against regulatory requirements.

This.

Isabelle49 · Oct 19, 2011

I don't think the question was how to formulate the 485, but how to create one. I could be wrong though, there are quite a few fly by night home health agencies.

KateRN1 · Oct 19, 2011

What do you see as the difference between how to formulate the 485 and how to create one? It seems to be the same thing to me. Unless Dunya is asking about how to create a 485 worksheet that the RN would use to tick off assessments and interventions based on diagnosis? And I still believe that should be created by a qualified clinician, not an unlicensed person.

RNDP2012 · Oct 19, 2011

Thank you all for your reply

I worked for different programs, one which i can run 485 based on RN's assessments . Then I used another program which the 485 was created Automatically based on the RN's assessments without me doing it which was really helpful and I think it should be like that.

Now , I am working with different program which has assessments and teachings for DXs but not comprehensive specially if we recert the patients . I was looking for Assessments that we can give to the nurses that can help us to build the 485 like a template.I have a book which is from has assessments , teachings , goals but they are just like one or two words not comprehensive and I was looking for detailed one.

Thank you

KateRN1 · Oct 19, 2011

I have a very detailed 485 template that was designed to be extremely specific, customizable for indivdualized care, and organized by body system. If you'd like a copy, please PM me your email address. Just a note that it is not currently in use by my agency (or any agency) and is not a trade secret. It was something that I developed on my own with the hopes of implementing it.

RNDP2012 · Oct 20, 2011

Thank you Kate . I am trying to pm you

Thank you so much

caliotter3 · Oct 20, 2011

RNDP you will not be able to PM Kate until you have made at least 15 posts.

RNDP2012 · Oct 20, 2011

Yes , I notice that but is there anyway to give her my email address? I really appreciate your advices here and your concern to help me .. God bless you all

caliotter3 · Oct 20, 2011

Although it is not advised, you can just post it outright. I don't think that is a good idea and I would not do it. My email was hacked recently when a website posted several email addresses in place of screen names. I am not certain if you can use the email function. It is the envelope icon next to the pencil and paper icon. You can compose an email and the AN site sends it blind so that you can not see her email address. Try to do that.