Is this the Norm?

He has a chart in the home? Are there records in it that refer to hospitalizations? Do you do his Plan of Care form (485)? Whoever is responsible for that should be informed when the patient is hospitalized and new orders, current dx, etc. reflected in that Plan of Care. The patient's doctor has to sign that form.

I think the person who updated his info dropped the ball. I do know that agencies can be left out of the loop and it wouldn't be unusual that his records aren't kept up to date. If there is no documentation in the chart of his post-hospital orders/dx start calling people until you get them. Agencies don't put their nurses well-being very high on their priorities, unfortunately. Hope it helps a little anyway!

Agencies frequently are left out of the information loop and it doesn't help when the person doing the intake doesn't make much of an effort to dig a little for pertinent info. It also was a responsibility of the patient's family to give as much info as possible according to their ability to grasp what is going on. Some people can talk to you better than the doctors on the case, and others don't want to have anything to do with the information, all they care about is that you show up at the house so they can go about their daily lives. You need to be on the lookout for all sources of info, particularly when you go to the doctor appointments with the patient. Don't be afraid to ask questions there and also to provide your input to the doctor.