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Marching Orders

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.

12 Comments Post a comment
  1. Pam #

    Yes, yes!

    February 23, 2016
  2. lisa Mingus #

    AMEN MY SISTA!!!!!!!!!!!!!!!!!!!!!

    February 24, 2016
  3. diana hamis rn #

    Actually, i always weigh my pt with the same scale and same place in there home, unless unable for some reason. Good tips so …thank you i learned from it.

    February 24, 2016

    • The use of the word, ‘always’ tells me you have made weighing patients a habit. Obviously, that comment was tongue in cheek because so often, I read charts where weights are missing. You set a good example.

      February 24, 2016
  4. Nicole #

    So much yes. I got a five page 485 back from the Coder, crammed with so many orders and goals there was no WAY I could get all that in in 9 weeks. Seriously? You want interventions and teachings and goals on every single diagnosis? All you’re going to do is force me to write a whole bunch of “goals not met” in 60 days. Stahp it. Let me focus on what the patient actually needs now. (Hint: that’s the stuff I clicked on and wrote in when I filled out the OASIS.) If they need something else in 60 days, we’ll get a Recert and focus on what they need then. But to my DON’s credit, I whined, she fixed it, and all was right with the world again.

    And I do (almost) always weigh, too. Except, of course, for the patients who refuse weights. Who are usually the patients who most need to keep a close eye on their weight. *facepalm*

    Okay, I’ll admit I didn’t weigh the 400+lb patient with hemiplegia. You teach me how to safely do that with one person (me) to assist, and I’ll do my best.

    And yes, our 485’s got fat when we switched to computerized charting. They need to be put on a diet. I’ll bring my scale. 😉

    February 24, 2016

    • Sounds like your coder has a bad, bad case of that clicking impulsivity disorder. It may be hard to hear but frankly, Diana, you are not that good! If you know that you are not going to meet a goal, it should not be on the care plan. I tried to include goals in this post but as it turns out, goals are a separate post due to the volume of information.

      In short, everyone’s goal is that the patient will not die or circle the drain on their watch. Don’t write that goal because some surveyors have no sense of humor. Start writing goals when you consider the greatest threat to a patients wellbeing. For an unstable diabetic, it may to reduce blood sugar to below 300. After an episode, you may adjust that goal to 200. What other risks does the patient face? Med errors as a result of a complicated med regime with multiple new medications? An infection to a wound? Those are the goals you want and honestly, three or four are enough.

      The dangers of superfluous orders are too many to count. The obvious one is that patient care suffers. When you have to wade through pages of orders to find what you need, you are burning time you do not have and there is a chance you will miss important information. If there is an order that you do not perform, you are obligated to notify the physician that their orders were not carried out. When the orders are too specific and chosen by someone who has never seen the patient, your emphasis might be on following someone else’s recipe and that person has never seen your patient. If designing care for a patient was that simple, it would not require the skills and critical thinking of a nurse.

      February 24, 2016
      • Nicole #

        (It’s Nicole, not Diana, but) again, YES! I’m a good nurse. Someday I hope to be an even better nurse. But even then, I won’t be able to bend space and time to fit 5 pages of interventions and education into 9 weeks. No one can learn all that in 9 weeks, even if I did nothing but talk at them for an hour a day for 9 weeks. It took me years of nursing school and reading on my own to learn all this stuff, and I actually WANTED to learn it! That was my argument to the DON: this is going to make us look like bad nurses, that we’re not able to accomplish all this. Let’s scale it back and focus on what’s important and achievable.

        I did not actually know that we were supposed to call the doctor about orders we couldn’t do though. THANK YOU! I’m going to be making a whole lot of phone calls tomorrow.

        February 24, 2016

        • I am so sorry, Nicole! Nobody should confuse you with anyone else. And I think the mistake happened at the end of my fingertips. I obviously need a visit to Chicago.

          When it comes to notifying the physician, think of it like this…. If you had an IV or med ordered and you didn’t perform whatever associated tasks, you would notify the MD. When stuff is added to the care plan and the MD signs it, it is an order just like IV therapy.

          February 25, 2016
    • Gail #

      Nicole, was your coder named Debbie? Just curious.

      April 1, 2016

      • Gail,

        Nicole is from Chicago.

        April 1, 2016
  5. Maggie Palmer #

    So far so good but what about wound care, picc lines, foley and s/p caths. We can’t forget those because we do have quite a few of them Thanks Maggie at IHH

    February 25, 2016

    • You are right, Maggie. All of those things, because they occur less often than they do, would be put under frequency on Planet Julianne. How you put them is up to the agency but I would try to be as consistent as possible throughout the agency so that nurses know where to find at a glance the details of the ordered care. And don’t forget teaching on those items. I know nurses do it all the time but I seldom read that a patient has been taught to keep the foley bag low and to report urine that is very dark, etc. The key again, is to write succinct orders that cover the required care and are not redundant. Specific suggestions are always welcome. One thing that is tricky is wound care orders when the patient goes to the wound care clinic. How do make sure new orders are available to the clinician before a scheduled visit?

      February 25, 2016

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