Atownshend

We have this problem all they time. It's not that the doctor is refusing to sign, they just won't get back to us for days. We have to hold visits until we get a call back. Lately we've had to do work arounds to get a verbal from the ma to get fax over to be signed, because for some reason the doctors can sign those so much quicker than just calling and saying, "yes that's fine". So frustrating.

So I'm trying to perfect my SOC process to shrink the time down in the home to make it most efficient. I want to minimize the time I spend being a questionnaire and maximize time for physical assessment and teaching. So I've come up with the following solutions. The first picture is the form I use for reminding me what to physically assess as well as information I get from the referral sheets. (Its printed on 1 x 2 pages so front and back are on top of each other.) It also has check boxes on the bottom reminding me to chart certain things I could easily forget on the profile page, etc... Then on the back of that one there is space for me to jot down their PMH, events leading to this admission, Goals, (both mine and theirs), my basic desired orders for when I call the md, and any issues that popped up on med recon to tell the doctor. This way when I call the md, everything is in the same place and I don't forget things like, "damn, I forgot to ask for a PT order!", or, "I forgot to tell her about that one med that wasn't on the list". The second form is one that keeps track of open charts that have yet to be coded, or need PT visit numbers entered, or need a call back for orders...things that are rarely completed the day of. This way I'm not shuffling through papers to find out what's outstanding. The last form, which I just cut and pasted on here, is a questionnaire I give the patient while I'm filling out their other forms with printed name/date/ etc... although I'm considering letting them fill these out and just highlight the areas I need from them because it takes time to do that I could be using to start their medication reconciliation. Anyway I hand them the check form which is similar to what they would fill out as a new patient at a doctors office except it has all the question and answer parts of the Oasis. This way I just glance over the form when they are done and ask some follow up questions and most of my visit is done already! Just the med recon, forms and physical assessment and teaching left. Then I can put everything in the computer at my own leisure. It has shaved about 30 minutes off my visit time. But these things still take forever. What do you think? Name__________________________Date of birth___________________Todays Date__________ If you are found to be a high fall risk, would you like physical therapy? Accept □ Decline □ What is your race/ethnicity?______________Do you have a living will? Yes □ No □ Who is your emergency contact?__________________Relation__________number_________ Is it ok to divulge your medical information to your emergency contact? Yes □ No □ Please list your drug allergies and what happens when you take them... DrugReactionDrugReaction ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ What pharmacy do you use?__________________________________phone number_________ List your doctors and their specialties _________________________________________________ ______________________________________________________________________________________ In the last 14 days have you had issues with the following? Check as appropriate. □ Incontinence of urine □ Urinary Tract Infection □ Confusion □ Incontinence of stool □ Impaired Decision Making □ Anxiety □ Urinary Catheterization□ Severe Memory Impairment □ Decreased interest □ Pain that wouldn't go away □ □ Depression ___________________________________________________________________________________________Do you receive IV therapy at home? Yes □ No □ Do you get fed through a feeding tube? Yes □ No □ Do you smoke? Yes □ No □ How many alcoholic beverages do you drink a week?________ Who is your primary caregiver and their relation?__________________________ What is your religion?________________ Height _____________ Weight__________ Do you have any of the following symptoms currently? □ Dizziness □ Numbness/Tingling □ Tremors □ Short Term Memory Loss □ Fatigue □ Chest pain □ Leg cramps |□ Long Term Memory Loss □ Palpitations□ Shortness of Breath □ Cough |□ Arthritis □ Gout □ Weakness □ Stiffness □ Decreased range of motion _________________________________________________________________________________________ Check as appropriate:YesYes Do you wear glasses? □ Do you wear contact lenses? □ Do you have Glaucoma? □Cataracts? □ Hearing Aids?□Hard of hearing?□ Partial Dentures?□Full Dentures?□ Missing Teeth?□Do you use Oxygen at home?□ How many Sleep apnea?□Cpap or Bipap?□ liters?____ Do you have pain? Yes □ No □ If yes, where?____________________________________________ When did the pain start?_________________What makes it worse?______________________ Is it worse during the day or night?____________ How long does the pain last?_____________ On a scale from 0-10, zero being no pain and 10 being the worst pain you've ever had in your life, what is the worst and best your pain gets? Worst________Best________ Describe the pain, ie throbbing, aching, burning, sharp, dull, discomfort?____________________ What does the pain prevent you from doing?_______________________ What do you do to relieve the pain?_________________Does the pain radiate? Yes □ No □ Is your doctor aware of your pain?____________ Do you have pain in another location? Please describe_______________________________ ____________________________________________________________________________________ Name_________________________________________________ Do you eat at least 1/2 of your meals? Yes □ No □ Do you have any open wounds? Please describe type and location__________________ _______________________________________________________________________________ Do you have a history of pressure ulcers/bedsores? If so where on your body were they?_______________________________________________________________________________________ Do you currently have the following when you urinate? □ Burning □ Frequency □ Urgency Do you occasionally leak urine i.e... when you laugh or sneeze? □ Yes If you do have incontinence or leaking, check the following: □ It is a problem day and night. □ It is worse during the day. □ It is worse at night. □ If I go to the bathroom at regular intervals I do not have a problem. When was your last bowl movement? Today □ Yesterday □ Other__________________ Are you on a sodium restricted, diabetic or other special diet?_____________________________ Have you lost 10 pounds involuntarily in the last 6 months? Yes □ No □ How many falls have you had in the last year? ____ How many in the last 3 months?______ In the last 2 years have you had the following tests? Check as applicable. □ Cholesterol blood test Women OnlyMen Only □ Colonoscopy □ Papsmear □ PSA blood test □ Rectal exam □ Mammogram □ PPD Tuberculosis screen □ Chest X-Ray Please check all the equipment below that you currently own. □ Standard Cane □ Hospital bed □ Dressing Stick □ 4 point Cane □ Trapeze □ Reacher □ Standard walker□ Raised Toilet seat□ Lap Tray □ wheeled walker□ Bedside Commode □ Special Eating Equipment □ Walker basket □ Bathroom Grab bars □ Splint □ Chair lift□ Handheld showerhead □ Gait Belt □ Wheelchair□ Long Bath sponge/brush □ Shower chair □ Transfer Board □ Long shoe horn □ Tub transfer □ Hoyer lift □ Sock aid Is there any medical equpment that you do not own but rent? Please list______________ ____________________________________________________________________________________ Last flu vaccine day______ month_______year_________unknown □ refused □ Last pneumonia vaccine day_______month__________year_______ unknown □ refused □ Are you diabetic? Yes □ No □ Todays blood sugar?__________ Your blood sugar range?_____ Have you been admitted to the hospital more than once in the last year? Yes □ No □ When is your followup appointment with your doctor(s)?_______________________________________________________________________________________

Just wondering if it is common at other agencies as an RN to only get SOC visits as a per diem (not hired as just an Oasis nurse). Since I learned SOCs that is all they have been giving me for 3 weeks. I make so much less money doing JUST SOCs. since I can do them in 3-4 hours that comes out to 19-25$ an hour, usually closer to the middle of that. Regular visits take anywhere from 30mins-1.5 hours and average to closer to 38 dollars an hour. (I get paid per visit). So if I had a mix of regular visits and starts then I would be fine but it is hard to pay my bills at this rate! Wondering if it's worth jumping ship or if it is like this everywhere. I've mentioned it to my supervisors and they give me "I understand what you mean" and then continue to assign just Starts, and when I said I would need only 1 start and some regular visits next time I worked, they said that would be difficult.

I used to have my hospital charting done on time in the hospital, too. And if we're talking regular revisits, my charting is done by the time I leave the home, but for admissions, there is no way.even if you get your oasis and assessment charted in the home three is still the notes, orders, 485, need reconciliation, Dr phone calls, profile, etc... I have made a form for patient's to fill out that ask all the basic symptom and demographic information while I'm filling out they're consent forms and what not to cut down on time in the home and also have written a computer program that fills out the oasis and assessment for what a standard patient looks like so all I have to do is chart by exception and change what's different for this patient and it still takes me 3- 3.5 hours to do everything on 1 start. If you have like one start/oasis (not including discharges, those are quick) and the rest are revisits it balances out and pay odd still good but if you have all oasis, which if you are an RN they can load you up with those, you'd make more money working half as much time I the hospital, but again, the stress level is much less in home health. It's just a matter of working 16 hours and getting paid for 6-8.

The acute stress is much less, I came from the er and have been doing it 6 months in hhc but once I started doing admits (I work per visit) what I'm making per hour plummeted. I'm making 19 dollars or less an hour and it's not just because I'm new, I've got it down to a science and from start to finish with coding, charting, getting orders, notes and all a start takes me from 3 hours and 15 min to 4 hours. I only get paid 76 dollars for each one. Is the stress worth the drastic pay cut? At the hospital I made 32 Ann hour plus 3$ an hour in cert pay per hour, but I dreaded going to work every day. I think if the pay in home health was slightly higher, like let's say 26$ an hour when you worked it out, what they pay clinic nurses around here in Florida, it would be worth it. We get a pay raise in December so I'm holding out before I switch companies, but I think I'll stick with home health.keep in mind though that I'm per diem and our full timers are salaried. From what I hear, hhc is one of the few areas in nursing where you can negotiate your salary, and you'd better, because they work the salaried nurses to death. They work from 8 am to 10 or 11 at night 5 days a week and take call on nights and have to take some weekends. I don't think it's worth doing full-time, they own you, and when the nurses complain they get, "that's the nature of home health"

I also added a checkbox next to the SOC at the top to check off that I filled out the assessment in the computer.

So I'm trying to cover all the bases I'll need to A. have all the assessment data I'll need to fill in the computer forms and B. Have a checklist of sorts to do all the extraneous SOC tasks. Let me explain the shorthand and you tell me what you think or if it is missing anything major. It is meant to be folded in half so that the fall and braden scales are on the back to determine fall risk score and braden score for risk assessment in orders without having to bust open the laptop and then the blank page on the back can be used for notes of whatever kind. FYI everything with a star next to it requires you to get out of your seat and touch the patient in some way. Everything underlined requires the patient to get up out of his chair. I ask the patient everything I can while they are sitting, and then verify their answers as needed when I have them get up. Everything with a pencil next to it can be done on the computer outside of the home even though I plan on getting the fall risk assessment # there so I can call the MD right afterward and know whether or not I'm going to be asking for a PT evaluation (we get one if the fall risk is >/10.) So from the left column top down, Why is this pt homebound, why do they leave home? Who do they live with at home; around the clock, during the day only, during night only, occasionally? Who is their emergency contact and is it OK to divulge information to them? How often to they routinely receive help from a caregiver? Who drives them to appointments? Is caregiver willing and available to learn given care (ie wound care, injections etc)? Check that forms are signed. Does this patient want to opt in to special needs shelter availability in case of a natural disaster? Does this patient have a living will? Did they give you a copy. When did this patient last have their flu vaccine? Their pneumonia vaccine? check that you document this in the non clinical note for the discharge nurse. What are this patient's allergies, reactions, and severity of reaction? What was the referral date for this evaluation? What date was the patient dc'd from the hospital, rehab, etc...if at all? What date was their surgery, if they had one? In the last year, have they been admitted to the hospital more than 1 time? In the last year, how many falls have they had? How many in the last 3 months? When is their follow up appointment with the referring MD(s)? Who are their other MDs and what pharmacy do they use? In the last 2 years have they had tests for cholesterol, colon CA, rectal exam, PSA, papsmear, mammogram, tb, and or chest xray? What is the patient's stated goal(s) for this certification period? At this point I skip over to the right column and will come back to the left in a bit. Is the patient Caucasian? (I put white instead of race b/c the majority of my patients are white and it's easier to put a check mark the majority of the time than to write in the race every time) What is their religion (see the little star of david and cross to represent that?) In the last 14 days has the patient had the following: incontinence, urinary cath, pain, impaired decision making, combativeness, severe memory impairment, UTI, confusion, anxiety, decreased interest in doing things, depression (italicized things are used in multiple parts of our computer system and help me to not have to ask the same questions more than once, I have to remember if they say yes to decreased interest and depression to ask them how many days in the last two weeks this has been the case I may put a # sign next to those two to remind me.) Do they receive IV therapy, peg tube feedings, enteral or parenteral therapy at home? Do they smoke, are they obese, do they have etoh or drug dependency? Neuro system assessment: do they have dizziness, Are they alert and oriented x 1 x2 or x3, numbness or tingling, tremors, paralysis, is ST or LT memory loss is impaired or irregular, is there a delay in their response time, is their jugement or safety impaired, is their attention span normal decreased absent or selective, (oops looks line I repeated judgement and safety I'll have to fix that) but is it good fair poor or labile, is their awareness of deficit good fair poor or labile, are they in a coma, forgetful, depressed, or lethargic, agitated, do they understand what you are saying usually sometimes or rarely? Anything in neuro those didn't cover? fill in the blank. Eyes: do they wear glasses, have glaucoma, cataracts, can they read their medication labels with corrective vision in place, if not can they see enough to avoid obstacles in their path? Are they hard of hearing, do they wear hearing aids? Do they wear dentures? I have to remember to ask full or partial and if they have missing teeth if they do not. Pain assessment, I remember to ask severity on 0-10 scale, what is the best and the worst it gets? how do they describe it, what makes it worse, what makes it better ,what does it keep them from doing, is it acute chronic or recent onset, does the MD know about it, does it radiate, etc... then is it mild enough to not interfere with activity, is it less than daily, daily or constantly? I ask all I can in interview form below before I touch the patient. interview items are bolded, which I think I will go ahead and do on my form, too. Then I actually go through and physically assess the things that aren't bolded. Remember that underlined things may have to be done either while patient is standing or laying later, for ease of access. So I skip those and come back to them later. Those things are Wounds (it may be easier to do when you have the patient lay down in bed if it is on the leg or stomach for example) Pressure ulcer check (you can't check the sacrum while they are laying down and heels are easier on bed as well) Pulses (pedal pulses and edmay be easier when the patient is laying) SOB (you have to watch the patient breath after movement) Skin: color, temperature, turgor, moisture, alterations Wounds: remember to write down size, appearance of peri wound and wound bed, drainage amount and appearance, closure, drains in place, etc... and what you did as far as wound care if it was ordered on referral orders. or if there is a non removable surgical dressing in place. Do they have a pressure ulcer what stage and size is it? Remember to ask if they have a history of pressure ulcers since anything over a stage III even if healed is assessed and documented forever. Do they have stasis wounds or surgical wounds? Cardiac: does patient have fatigue, how are their pulses in their extremities, how is their cap refill, leg cramps, vericose veins, syncope, palpitations, are the legs cold to touch, do they have a murmur? Do they have edema, remember to document location and severity. Do they have vascular access in place? What is it's purpose and what kind of access is it? Respiratory: Do they have SOB? (underlined so you can observe) What do you hear on auscultation? Do they have a cough? do they use O2 or respiratory treatments or cpap? remember to document sputum if they have any. GI: when was their last bowel movement, how does their abdomen feel? How are their bowel sounds, do they have fecal incontinence? What is their diet and how is their appetite? Remember to document ostomy if present and it's size and appearance and part numbers etc... GU: Do they have incontinence? does timed voiding avoid incontinence? mostly during the day? mostly at night? remember to document any urinary symptoms like burning, urgency etc... also urostomy info as above if present. Blerb to the right is to remind me to document about psychological illess history that is referenced at top of column. Musculoskeletal: does patient have arthritis, gout, weakness, stiffness, leg cramps, decreased range of motion, deformities, un equal grasps (indicated as a reminder on left column near O2 as a little hand icon), paralysis, amputation, gait (arrow indicating that this is to be assessed and noted on left column), appliances (arrow indicating that this is to be assessed and noted on left column). I skip Wound supplies and Venipuncture for now and move back to left column. Before you have the patient get up do the starred items that can be done sitting in the chair. Ask the patient how much they weigh and how tall they are and if they have had a loss recently and how much. Check patients temp and respirations and O2 sat if ordered. Check patient's hand grasps. (the question mark to the left of the star on this row is to remind you that there is a question to ask, ht&wt and loss, the patient here as well as the action of taking those vitals). Ask the patient how they normally handle the items below from transferring to using the phone. Then ask them how they normally take their PO or SQ meds if applicable. This way you know a little more what to expect when the patient actually gets up. Now have the patient put his money where his mouth is and GET UP! Tell him to take you to the bathroom where they get up in the morning. Watch him transfer, and ambulate, what device is he using, is there someone there helping him, how much help does he need, how much more help should he be having to be safe? Tell him to pantomime brushing his teeth and hair with his toothbrush and comb. Could he do this if the items in question weren't within reach? Have him get into the shower and pantomime washing his hair, take note of adaptive equipment in place and what he could use that he doesn't have. Have the patient sit on the toilet and show you that he can reach his behind to wipe, does he look steady? have the patient show you where he keeps his clothes and pantomime putting on a shirt and socks. Is he steady? Ask the patient if he feeds himself, who cooks for him? Could he reach his food and microwave safely if he had to? without hands on an assistive device? Without pain putting him at risk for injury? Can he use the phone? Get to the phone? The next blerb is asking if he had decreased balance while sitting, standing, and or walking, and PU is to remind you to check for pressure ulcer before he sits back down. Now is where I have them take me to where they sleep and lay down in their bed. the horizontal arrow is indicating laying BP and heartrate. It's at this time that I Do the underlined things on the right column. Wound assessment and wound care, writing down wound supplies, checking sacrum and heels if they are too unsteady to check while standing, pedal pulses, leg edema. Then I do standing BP and heart rate, indicated by the vertical arrow. Did their pressure drop 20 points? Then I have them sit back on the bed and do the timed up and go test. Get up, walk 10 feet, come back and sit down. How many seconds did this take? scoring on back. Now I have them take me to their meds and walk through them with me. Read me the med names tell me what they are for and when you take them. I do the med rec at the same time. I ask if they are diabetic what is their normal range of FSBS and what was it today, if they check it? Do they draw up and inject it themselves? I ask them if they have the eqipment listed below, if any of it is rented, and I verify what they say with what I saw when we took our walk. At this time I take blood if ordered and write it down at the bottom of the right column. Venipuncture what test was drawn, from what site, what lab did you drop it off to? check box that you documented it. I grab my forms and cheat sheet, thank them for their patience, tell them I will be calling their doctor for orders and what orders I will be asking for, and tell them someone will be calling to set up their next visit and when I anticipate that to be, although nothing is written in stone. Then I leave and go somewhere comfortable (probably my car, LOL, although starbucks would be nice, it's always crowded.) And do some of the pencil things. Let me go through and explain what they all are. VSprm: are there any vital signs or other parameters I think the doctor should put on the patient? BP? Weight? FSBS? Does the patient have the following? DM, pressure ulcer, high skin risk according to braden score, fall risk according to scale, pain, depression hx or indicators Call the MD first check box is you put a call out, second is they called you back. Did you get a PT eval order? or was there one already? the line next to that is how many visits the PT thinks they need after they do their eval so you can put it on the oasis along with OTorder which means either OT visit number or "other" such as social worker etc... Total number of other discipline visit estimate according to the orders they put in goes in Visit # so you can put it on the oasis. Put in notes to your coder (ours is stacy), a general admission note for the case manager, a note to scheduling to generate visits for orders when in, and a blerb on whether or not this patient is appropriate for an LPN to see in that note, and a note for PT eval visit generation for schedulers. Mark the patient as admitted, start the 485 once you get your orders, make sure to put the fall risk # in the order to justify PT eval or absence of one due to risk, charge the patient for supplies used or left in home, turn in signed paperwork, HHG is a form we get emailed to us to reconcile irregularities in charting and evaluate if we would like to change them. Enter codes when they come in from coding company and enter severities, refresh the 485 to include codes, get the OK from your supervisor to lock down charting, and lock down order, change the date on the bottom of 485 to reflect SOC date, lock 485 and lock visit note. Phew, it looks like so much less when written in short hand! Any suggestions for improvement of my cheat sheet or process? Thanks!

I use mapquest route planner to try to minimize drive time. I also wrote a macro that fills out the computerized assessment form according to the last visit so that not only do I get a report of sorts going through the screens but I only have to change what is different. This saves me about 10 minutes a visit but took many hours to write, as it is over 5000 lines of code. I used autohotkey to write it. I'm payed by the visit per diem so it is in my best interest to be as efficient as possible. I just started doing start of cares (only been doing this about 6 months) and although with regular visits I usually have my documentation locked and complete with charging and notes and all, I'm going to experiment this week with using an oasis cheat sheet I made for SOC so I can reduce my time in the home since it seems there are so many steps that utilize the assessment info that it would be easier to see it all in one place for reference rather than coming in and out of the screens in our program (McKesson). I've got all the info and steps I need with checkboxes for tasks completed or things documented on one half of a sheet of paper with fall risk assessment and Braden on the back. And even though it was a pain the first time, I think a macro that prefills the oasis for what a healthy patient would look like so I don't have to waste time filling millions of wdl boxes and can chart by exception will save boatloads of time. I also make the lab draw kits like the previous poster. I like to write an order draft and note draft the night before so I can just add or take away as needed according to assessment and I outline the teaching in my note that I'd like to do so it functions as a to do list of things to discuss with the patient. This also allows me to call the md pretty close to the end of my visit to give for a verbal ok on my order to give them the max amount of time to call me back so I'm not waiting on calls into the next day when I'm not working. I'd love to hear other peoples tricks!

Jeez it must suck to drive around in snow half the year, I've lived here pretty much all my life and I didn't realize it was that long you guys get asks up north. It must really slow down traffic.

I live in Florida and we don't have a lot of high rise type places here. Mostly houses and some condos, most with elevators. Does that make a difference? Also, what about the pockets. Would those work?

I move in Florida and we don't have a lot of high rise type places here. Mostly houses and some condos, most with elevators. Does that make a difference? Also, what about the pockets. Would those work?

http://www.amazon.com/Rest-n-Roll-STND-1-Deluxe-Multipurpose-Carrying/dp/B007D446GK/ref=sr_1_1?ie=UTF8&qid=1398911005&sr=8-1&keywords=rest-n-roll I'm starting in HHC next week and was debating on this bag. After doing my ride along I noticed that not having a place to sit while documenting on the laptop or doing a dressing change on a leg while basically standing on your head seemed really annoying. I wouldn't want to sit on anything in a patient's home (I've head horror stories about urine soaked chairs). What do you think...It could also work as a work surface for dressing supplies.

I just started with my hospital's company's HHC agency. Per diem minimum is 6 days every 6 weeks but they prefer double that. No weekend requirements but you can if you want to. Also one summer holiday and one winter holiday yearly. No call.

I made some changes to the body of the cover letter... This is in regards to the per diem home health RN position available on the intranet. I am very interested in breaking into the home health care field, and with 5+ years of acute care experience, I would make a great addition to your team of nurses. My personal values have always been aligned with the I-CARE values. This coupled with a positive attitude helps me go the distance in providing our patients with a positive customer experience. I have worked tirelessly to not only make my personal practice as organized as possible but also to help to standardize and organize practices on the unit through the development of organizational tools. My updated admission tool and packet was published on (document software name) for use by our nurses on (hospital floor) and helped to streamline processes and avoid redundancies. This allowed our nurses to spend more time with our clients. In the last year I have had the opportunity to work as an emergency RN at (hospital name). The variety and exposure have been invaluable to me and I have seen everything from newborns to centenarians, simple coughs to sepsis, and sprained ankles to broken bones. This has increased and strengthened my skill set. I have long had aspirations to become a home health nurse and feel that my current skill set would translate nicely. I have researched home health nursing, am ready to make the jump and hope to stay for years to come. Thank you for your time and consideration. I look forward hearing from you and finding my “home” in home care.

I made some changes to the body of the cover letter... This is in regards to the per diem home health RN position available on the intranet. I am very interested in breaking into the home health care field, and with 5+ years of acute care experience, I would make a great addition to your team of nurses. My personal values have always been aligned with the I-CARE values. This coupled with a positive attitude helps me go the distance in providing our patients with a positive customer experience. I have worked tirelessly to not only make my personal practice as organized as possible but also to help to standardize and organize practices on the unit through the development of organizational tools. My updated admission tool and packet was published on (document software name) for use by our nurses on (hospital floor) and helped to streamline processes and avoid redundancies. This allowed our nurses to spend more time with our clients. In the last year I have had the opportunity to work as an emergency RN at (hospital name). The variety and exposure have been invaluable to me and I have seen everything from newborns to centenarians, simple coughs to sepsis, and sprained ankles to broken bones. This has increased and strengthened my skill set. I have long had aspirations to become a home health nurse and feel that my current skill set would translate nicely. I have researched home health nursing, am ready to make the jump and hope to stay for years to come. Thank you for your time and consideration. I look forward hearing from you and finding my “home” in home care.