Change in primary diagnosis after hospitalization

  1. What is the best way of documenting a change in primary diagnosis and all the changes in treatment and meds as a result of this at the resumption of care. Is there any specific form that anybody can recommend? I want to make sure that all the team members or if a new nurse is assigned to the case, can see this information clearly. We do not write a new plan of care(485) at ROC, I doubt if anybody else does it??

    Thank you
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    About Sana2007

    Joined: Apr '09; Posts: 29; Likes: 3


  3. by   annaedRN
    When we perform a ROC we do a new 485 as well. Solves the new diagnosis/meds/treatments/teaching problem easily. We are on computer so everyone can see new changes
  4. by   HmarieD
    A thorough ROC order should do it. You also might consider a SCIC OASIS (Significant Change in Condition). These no longer impact reimbursement, but will reflect the multiple changes in your pt's condition.