need help oasis summary tips!

Specialties Home Health


Specializes in HHN, ICU.

hello everyone, i'm new to home care nursing barely 2 months, need tips on how to write good summaries on SOC, ROC, recertification and follow up. what are the important stuffs to include in the summaries. any samples of your narrative or format will be greatly appreciated. thank you.

Specializes in Infusion Nursing, Home Health Infusion.

This is what I do:

1 I always address why the pt is receiving home care

2 I always state what nursing care was provided

3 I always state the pts response to the prescribed tx or regime the nursing care and teaching provided

4 I always address any complications that have occurred during that time frame and any change in the plan of care

Specializes in HHN, ICU.
Specializes in COS-C, Risk Management.

For ROC and recert, it's really easy--document what is addressed in the 485. Look at your goals and document whether or not patient achieved the goals, if not, why, and if more treatment is needed or if it's not warranted. Any complications and how they affected the goals. Who you spoke to at the dr's office with notice of recert or ROC.

For SOC, a head-to-toe assessment, homebound status, availability of caregiver, physician notification, and any issues that you can see upfront (forgetfulness, sx of undiagnosed dementia, lack of electricity, etc.).

Specializes in HHN, ICU.
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