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Medications
60 Day Summary
Regulatory
Orders
Visit Notes
100
According to our Best Practice, the medication review must be completed at these intervals.
What is at least weekly or on every visit if the patient is seen less often than weekly
100
Must be completed at this frequency.
What is at least every 60 days?
100
Two sets of regulations that govern home care in MS
What are CMS Conditions of Participation Mississippi State Minimum Standards
100
This document is established with the physician based on the findings of your assessment and it directs the care to be rendered to the patient.
What is the 485 or Plan of Care
100
Location and time that is optimal for completion of the visit note.
What is in the patient's home during the skilled visit?
200
Form used to update medication profile in the computer
What is the patient information change form
200
This part of the summary documents medical necessity for keeping the patient on home health service.
What is "rationale for continuation of care"
200
The best guide available to you to help guide your documentation
What is the 485 or Plan of Care
200
Two signatures that should be included on every note.
What are the nurse making the visit and the patient/cg?
300
Number of copies of medication profile printed following a change and purpose for each.
What is three...One for green chart One for Blue chart One for patient
300
The 60 day summary should always contain this information on every patient.
What is vital sign ranges, weights, and blood sugars (when applicable)
300
These people should have a copy of all current orders on the patient.
Who are the case manager, the clinical supervisor or director, and the physician?
300
9:00 am the day after the visit
What is the time the notes should be turned in at the office?
400
If one of these medications changes, we must make a visit by the end of the next day to instruct the patient/caregiver.
What are high risk medications
400
Progress toward goal attainment should summarize this.
What is EVERY GOAL on the 485 for this patient
400
This is the possible penalty we may have levied if we fail to follow our physician orders and put the patient in danger.
What is immediate jeopardy?
400
Must be addressed and documented on each visit.
What is the primary diagnosis?
500
List the high risk medications
What are: Anticoagulants (Warfarin, Coumadin, Heparin) Hypoglycemics (Oral) Insulin Diuretics (Lasix, Bumex, Aldactone) Inotropics (Lanoxin, Digoxin) Narcotics/Opiates TPN
500
Information that should be included in the summary section of the 60 day summary
What is... "Poor/Pitiful" information about patient Medication changes Treatment changes Hospitalizations Lab results wound measurements Vital sign ranges...weights and BS is applicable Disciplines involved in the patient's care
500
Medicare rules specify that physician orders must indicate these three things.
What are Type or nature of service to be rendered to the patient The professional who will render the service The frequency of the service to be rendered?
500
One mistake QAPI sees repeatedly that could result in immediate jeopardy.
What is "wound care performed according to order dated" space on the addendum of the note?