Need Help With Care Plans

[amesly15]

The agency I am working for is looking at using the 485 as the Care Plan. Does anyone else do that? We are on computer and there is so much documentation that can be used. My concern with working off the 485 is the teaching documentation would be lost in notes. For example --teach medication use and side effects could be on the 485...but in the notes a nurse could teach the same med over and over and not teach a different med--without a careplan history of what has been taught and what is left to teach. Any help would be appreciated.

[nurselulu]

the agency i am working for is looking at using the 485 as the care plan. does anyone else do that? we are on computer and there is so much documentation that can be used. my concern with working off the 485 is the teaching documentation would be lost in notes. for example --teach medication use and side effects could be on the 485...but in the notes a nurse could teach the same med over and over and not teach a different med--without a careplan history of what has been taught and what is left to teach. any help would be appreciated.

hi, i am relatively new to hh (1 year down) but our agency uses the 485 as the care plan and it seems to work pretty good. the nurses have the opportunity to choose different teaching subjects from the 485 but i agree with you, there isn't a way to track that to see what has been taught unless we keep track through the nurses notes but as you said, it gets lost & would be a time consuming project. are you medicare/medicaid agency? we do private duty nursing at present, but we are soon to be medicare/medicaid certified. it will be very good for our area and i know we are going to become very busy. as a new hh director i could use some tips and hints. i'm glad to find this hh part of the sight.

would love to correspond with anyone out there. thanks,

nurselulu:nurse:

[jeanneb1]

Hi, Fellow Home Health Folks. The 485 is the plan of care, and I've always used as the careplan. How you track what's been taught is by placing a teaching log in the home folder -- as a med/procedure/etc. is taught, it is documented on the log, so the next nurse in the home (or, the same one on a day that dementia clouds the brain!) can readily see what's been taught, can question pt/cg to see if knowledge was understood and retained, then can re-teach with proper documentation of pt/cg confusion/forgetfulness, etc., or move on to something else. The teaching log, when full or completed, goes into the patient's chart as verification of services performed/information taught. It's a good, simple, effective tool.