home health travel chart

caliotter3 · May 2, 2008

Each agency has a different approach to the field chart (chart kept in the home). Most agencies include some or all of the following: copy of the contract and associated admit forms (patient rights), forms documenting safety check of home and disaster plan, copy of current 485, copies of submitted supplemental MD orders waiting for signature and/or inclusion on 485, copy of nursing care plan, copies of forms documenting nursing assessments, current month or week MAR, TAR, applicable flow sheets (ventilator, I&O, VS, BS), copies of lab work results, copies of reports from other disciplines, copies of latest physical exam, copies of nurses notes from previous visits, copies of DME cleaning records. You will go into some homes of an established case and find a field chart that is well organized and very complete, while some agencies won't even have a copy of the current 485. The 485 is the most important document since it lists the MD orders for care to be performed during your shift. You can't just go by hearsay of the patient family and the labels on medication bottles can be out of date or incorrect. You're required to follow the current MD orders, as signed off on the 485.

Nurses should be provided their own copy of the 485 to review before going to a new case. With this, and your own supply of blank forms, you can do your visit or shift, even if the home chart is basically non-existent. HTH