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.
iluvivt, BSN, RN 2,773 Posts Specializes in Infusion Nursing, Home Health Infusion. Has 32 years experience. Sep 6, 2010 This is what I do:1 I always address why the pt is receiving home care2 I always state what nursing care was provided3 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
KateRN1 1,191 Posts Specializes in COS-C, Risk Management. Has 20 years experience. Sep 7, 2010 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.).
