The Home Health 485 is supposed to be more than a regulatory requirement but that’s not how the document is approached by many nurses. Making things worse is the epidemic of the condition, not yet named, of the irresistible impulse experienced by nurses in the presence of computers to click any and all open checkboxes resulting in hundreds of orders for a patient who doesn’t have half of the diagnoses that the orders are addressing.
Back to Basics
What’s wrong with a simple care plan?
Consider doing this when you get to the orders section of the care plan. First, skip a few lines. We’ll get back to those.
Next, try to avoid something stupid like, SN to assess all body systems or SN to perform total body assessment. If you perform a total body assessment on a patient, please email me privately. We need to talk. You have no business going into the complexities of a complete neuro exam. There is no point in verifying that all 12 cranial nerves are functioning as they should be; nor should you ever ask a patient to bend over and cough in the home. Let a physician or nurse practitioner handle the breast exams and anyway, you certainly wouldn’t do one every week for nine weeks.
Try this instead.
SN to assess patient according to flow sheet and report all out of range parameters to MD according to the following:
Here is where you put vital signs and certain other things you should look at and report. For blood pressures, separate the parameters. I have been known to stare at a blood pressure of 140/110 for an hour trying to figure out what to do because the parameter is 150/90 and only one number is out of range. State your systolic and diastolic pressures.
Heart rates are pretty simple but always note if the patient has a pacemaker and what the settings are. Also, adjust for a patient on beta blockers because if your patient on Lopressor normally has a heart rate in the low 60’s and suddenly is sporting an energetic 94, there’s a good chance they did not take their medications.
Respirations are pretty easy to figure out. The main thing is that they have them. Temperature should never have three digits before the decimal and for as long as I have been nursing, I have never had a patient whose temp was too low. Maybe you have. Please weigh in in the comments section if you have. (Note, I have never taken care of pediatric patients…)
You might as well add weight parameters for patients with heart failure, renal disease and other conditions where weight matters. It’s not like anyone ever weighs patients but the surveyors will want to see the order that you didn’t follow.
Don’t stop with the basics. Include blood glucose (only if the patient is diabetic), pain and INR’s. Anything that needs to be monitored on a frequent basis needs to be in the parameters section. And they need to be individualized. A patient admitted with no pain should not be reporting severe pain prior to notifying the MD – cut them a break and call a little early.
On all visits, medications should be reviewed. I’m not talking about reading a list of what the patient is supposed to be taking. I am referring to the process where you actually look at the medication bottles and compare them to the list. So your next order might read:
SN to review medications against orders and address any discrepancies, new or absent medications and high risk medications.
I can pretty much guarantee that your level of skill will increase if nurses do this each visit. A single phone call to the MD to verify that he wants a medication continued followed by a phone call to the pharmacy to call in the script is a skill, folks. Not only that, it is an important skill.
Most patients have teaching ordered. Here’s a tip. If you take a break from writing your care plan and find a good teaching guide from a reputable source that addresses the patient’s primary diagnosis, you can save yourself a lot of time. When looking, consider if the patient needs low literacy teaching or just an overview of a condition that is long standing. If the patient is a diabetic, he or she may know a lot about diabetes but somehow wound up with a foot ulcer. In this case, you may want to focus more on diabetic foot care. If your computer system allows it, upload the teaching guide and then make a copy for the home. Now your order reads:
‘Teach diabetic foot care according to teaching guide’.
Other teaching might involve teaching a family member how to care for a patient. Whenever possible, be specific. Are you teaching the patient’s husband or second cousin? It matters. Who is this pt./cg? Is it the patient? The Caregiver? Both? Who can tell with the Pt./Cg. Designation. If you were ever sued because you taught Pt./Cg. and they couldn’t be produced at court, you might have a problem.
Wound care is pretty much exactly as the MD orders. If they are vague in their orders, call them. Write those orders in a recipe format so even nurses who don’t often do wound care can follow them. Even if you do not have orders to teach the family how to perform wound care, include an order to teach the caregiver how to assess the wound and when to call MD.
Finally, consider your medications again. Which of the medications have a high potential for side effects or a narrow margin of safety? If there are any that are new and meet the prior guidelines, be sure to upload separate teaching guides for them and list them in the orders. Your order might read:
SN to teach medications with emphasis on Coumadin and insulin.
Now, look back at your orders and think about how much time it may take you do to all of these things. Write your frequencies accordingly and write orders for lab in the lines we skipped at the start. Note: Do not write an order to draw lab according to MD orders when there are no orders. When you get the order you will have orders. You do not need an order to follow orders once they are received.
I understand that this care plan methodology won’t cover every patient but it sure will cover a lot of them.
How would this work if you were seeing a patient that was new to you? Would you prefer to see everything on the first page without a lot of ‘filler material’? Would it take less time to write?
I know that many nurses do not write care plans like this. What am I missing? I seriously want to know.