How to you organize a visit?

I'll add that I typically do my assessment first, then continue with skilled care after, then complete my paperwork.

For a SOC visit, it depends on the patient. Usually, I will introduce myself, our company, review the handbook, sign consents. Obtain medical history and then do the functional assessment, home safety eval/walk through. Then, I do vital signs, assessment, and hands on care.

For a regular SNV, I review any changes since the last snv, review any med changes and teach on new meds, review the body systems, then hands on assessment/wound care, then VS.

For a soc I go over our HH packet and get them to sign a consent. I think start on my assessment and do that in full and then do oasis and just get back up if forgot something. For routine wound care I do vitals and assessment and then document wound and do teaching at end.

Thanks that helps a lot. I feel as a new HH nurse I am always forgetting something along the way and can't wait until I have a nice flow down. I think that time management is Huge in this aspect of nursing.

When doing a SOC, I start with the paperwork, first explaining and getting admission consent signed, then we have 3 other places that need a pt signature, so do those at this time: emergency form, another medicare/financial form and the soc OASIS, explaining each form during this time. For the OASIS, I tell the pt that everything I do at this visit will be on this form and it goes to Medicare.

Then I go through a medical history and meds. During this time I learn a lot about the pts memory, and even their ambulation and balance when they get up to get meds. Then I do a physical assessment, whatever specific the pt needs (wound care, PICC meds, etc), some basic teaching and explaining what the poc will be and how home health works in general. Then I usually do the TUG, and ask to see their bathroom set up, asking about safety and ADL issues. Just by doing this, you can learn a lot about mental and physical status, check for dyspnea, a lot of other things.

I also include explaining our home folder and the information inside, and making sure the pt knows when and how to call us if needed.