Orders & Documentation
What must be entered at every SOC that you get from the discharge/referral paperwork?
What must be documented with PRN meds?
How soon must routine visit documentation be completed?
What should you do BEFORE calling the office for updates on your patients?
What is the correct process to upload a photo?
Use OneDrive
After SOC, what do you enter to get your plan of care orders pushed through?
When should vitals be taken?
Every Visit
What should you do if you are struggling with timely documentation?
How do you request orders to be faxed for providers that require faxed communication vs. verbal order requests?
Enter a clinical note for the CM to copy your order request into a written order request.
What is the process if you are calling in sick?
1. Notify Katie or Jaycie - via teams, text, or phone call
2. Call (if able) and reschedule your patients
3. Send visits back to reassign if you aren't rescheduling and send a message in your office chat any patients that need to be called for you.
What type of visit is plotted on the calendar at the end of an episode?
Recert (visit code 02)
What is the most common PRN documentation mistake?
If you are assigned a wrong visit type what do you do?
Re-assign to office and enter a scheduler notification note.
Who do you call if a patient is a non-admit?
What is bag technique?
Bag on bag barrier or hang from a chair (Never place on floor)
Ensure you have a clean area and dirty area and clean any supplies used prior to putting back in your bag.
Always sanitize or wash your hands prior to going into your bag and between tasks before touching a patient.
Why might you NOT be able to see a subsequent visit on your tablet?
Why are PRNs important for audits?
Why is it important to complete your documentation timely?
What do you do if you find out a patient is hospitalized?
When should you review medications with a patient?
Every visit.
What steps do you need to take to remove subsequent visits following a discipline dc earlier than originally planned?
Update provider, enter a physician order (no need to send for signature) and select calendar and remove any remaining visits following your discipline dc (i.e.: RN19)
You learn that your patient is using a PRN medication daily. What’s your next step?
What are the visit codes and their meaning?
00, 01, 02, 05, 15, 17, 18, 19
00 - Start of care (SOC)
01 - add on discipline evaluation
02 - Recertification (RCT)
05 - ROC/RCT in 5-day window of end of cert
15 - Resumption of care (ROC)
17 - OASIS follow up for change in condition (SCIC)
18 - Discharge from agency
19 - Discipline discharge
44 - Transfer to Inpatient Facility (TIF)
66 - Agency dc without in person visit
88 - Death in home
Supervisory requirements:
PT/PTA
OT/COTA
RN/LPN
PT/PTA - direct sup visit every 6th visit with PTA or less.
OT/COTA - indirect sup visit with COTA every 30 days and documented coordination of care in chart.
RN/LPN - indirect sup visit every 60 days at minimum
Bonus: If/when we have HHAs come on staff, what is the supervisory requirement?
What are 3 main things that are required to be in every patient's home when on services?
1. Updated medication list
2. Calendar with your next appointment planned written on it.
3. SOC folder