Please help re: written 60 day summary

annaedRN, RN · Apr 20, 2009

A summary is going to be written at end of the cert period. It's a progress note if the patient has not met the goals - a summary of how everything is going (VS, ADLs, wounds, infections...) and that they still need to be seen for x times in the next x weeks. If the goals are met, then a discharge summary is written. Still write about the overall progress the patient has made and that they met goals, are independent, no further need, etc. If we recert then we send the progress note and if we discharge the summary is available upon MD request (if it was a complicated patient- I usually send it though). We make a phone call to inform the MD either way as well as write an order to specifically recert or discharge. Hope that helps!

MaryMc/RN/CM · May 25, 2009

The 60-day summary info is spelled out fairly concisely in the book by Marilyn Harris titled "Handbook of Home Health Care Administration", 2004 edition, on page 40...... you can find a preview of the book, including pg 40 under a google search "home health 60-day summary information", and possibly under an amazon book search. Be aware/advised.....I've discovered over the years that this 60-day summary form and its contents varies widely from home health agency to home health agency......some want just the patient info...generally adverse facts from the last 60 days, other's have you add each and every physician contact, including the physician reply and/or any new physician orders, (even though the physician himself wrote the order, you have to tell him what he did over again, including telling him you found a new drug in the home, even if the script has his name on it)...smile....anyway it should include the pertinent facts from things like...lab work, the "H's" & "L's" rather than each lab value, etc., did the patient fall, get injured, how many times, is the patient compliant with his medication regime, is he allowing PT to come for each scheduled visit, is the nurse able to contact and visit the patient when scheduled, ie., is the patient still homebound, or is he/she to weak/fatigued/HOH to answer the door..., was the patient seen in the ER, was he/she hospitalized longer than 24 hours, has the patient benefited from PT, OT, or a home health aide the past 60 days, has any diagnosis worsened, any exacerbations of existing problems, timely healing of wounds, new infections, has the patient been seen by a different doctor and received new meds, or had new problems identified by that physician, for instance...was seen by a cardiologist and is now on coumadin, seen by a pulmonary doc and had a nebulizer ordered/delivered and needs instructions, was put on O2, etc..... What are your new nursing goals based on the identified problems/changes, what changes were made, or added to the plan of care...sometimes you'll just be continuing an ongoing plan of care/treatment...are your patient discharge plans still the same....., if more than one nurse made visits, you'll have to go through the patient's chart to see what occured, including other dicipline notes/reports from PT, etc..... Some of the criteria will depend on your state and your agencies specific policies....the 60-day summary form your agency uses should help guide you..... Hope this helps...please let me know.........

Sana2007 · Jul 22, 2009

The 60-day summary info is spelled out fairly concisely in the book by Marilyn Harris titled "Handbook of Home Health Care Administration", 2004 edition, on page 40...... you can find a preview of the book, including pg 40 under a google search "home health 60-day summary information", and possibly under an amazon book search. Be aware/advised.....I've discovered over the years that this 60-day summary form and its contents varies widely from home health agency to home health agency......some want just the patient info...generally adverse facts from the last 60 days, other's have you add each and every physician contact, including the physician reply and/or any new physician orders, (even though the physician himself wrote the order, you have to tell him what he did over again, including telling him you found a new drug in the home, even if the script has his name on it)...smile....anyway it should include the pertinent facts from things like...lab work, the "H's" & "L's" rather than each lab value, etc., did the patient fall, get injured, how many times, is the patient compliant with his medication regime, is he allowing PT to come for each scheduled visit, is the nurse able to contact and visit the patient when scheduled, ie., is the patient still homebound, or is he/she to weak/fatigued/HOH to answer the door..., was the patient seen in the ER, was he/she hospitalized longer than 24 hours, has the patient benefited from PT, OT, or a home health aide the past 60 days, has any diagnosis worsened, any exacerbations of existing problems, timely healing of wounds, new infections, has the patient been seen by a different doctor and received new meds, or had new problems identified by that physician, for instance...was seen by a cardiologist and is now on coumadin, seen by a pulmonary doc and had a nebulizer ordered/delivered and needs instructions, was put on O2, etc..... What are your new nursing goals based on the identified problems/changes, what changes were made, or added to the plan of care...sometimes you'll just be continuing an ongoing plan of care/treatment...are your patient discharge plans still the same....., if more than one nurse made visits, you'll have to go through the patient's chart to see what occured, including other dicipline notes/reports from PT, etc..... Some of the criteria will depend on your state and your agencies specific policies....the 60-day summary form your agency uses should help guide you..... Hope this helps...please let me know.........

Very helpful information. But can you tell me if a progress note is different from a Summary report? The previous entry says that it is the same, only calls different depending on if used at Discharge or recertification. Is that right?

Thanks fo your input.

PCUSheryl · Dec 28, 2009

The agency I work for now requires a discharge summary for every discharged patient, even tho every 485 states we will send discharge summary upon request. The agency I worked for previously didn't require a dc summary unless requested by the Dr, which was extremely rare.

cecilia66 · Jul 5, 2012

can a 20 year experienced medical historian do the 60/DC summary for the D.O.N to review and sign? that is what i do for a HHC agency for the past 2 years, we have just passed a Medicare audit and noted no problems with my summaries, however they aren't aware i am not a RN. I would like to know if that is legal or not.