Consents/Emergency Forms
Signed by the clinician at SOC, ROC and Recerts.
Emergency form and upload it each oasis timepoint to the chart.
What should the documentation support at each and every visit?
Necessity of skilled service, and homebound status
Left in the home after performing wound care
Specific wound care orders
Level 2 medication interaction requires you to do what?
Call the MD and document!
Level 2 medication interaction requires you to do what?
Call the MD and document!
PT/RN/OT/HHA require an additional consent type if they aren't the one doing the SOC.
What is an add on consent?
It's ok to put your bag on the floor if you use a drape/barrier.
Surgical wounds don't have to be measured: True/False
False - all wounds require a measurement
Elements of a SMART goal are:
Specific, measurable, achievable, relevant and timely
Elements of a proper medication profile entry for an antibiotic
Start date, stop date, dose, route frequency and PRN parameters including reason
Which photos are taken at SOC and later by add on clinicians?
Home Health Consent, Emergency Form, exercise packets from PT/OT, all medical education, Medication list
This must be written for each PRN medication.
What is "as needed for...."
You must click the PRN box AND type "as needed for whatever ailment or symptom" if you are not typing "as needed" then it is not being filled out correctly :)
Elements of a wound care order:
Frequency, removing dressing, cleaning with specifically, redressing the wound. Who will perform the dressing change. Observing and teaching signs and symptoms of infection
This must be included as part of the OT plan of care.
What is the Functional Mobility Pathway
Start date of a medication that a client has been on for years should be? Start date for a new med should be?
A few years prior the the current one. All new meds should have exact starting date.
Which disciplines should be noted on the consents?
PT eval, OT eval HHA visit frequency, MSW eval, SKILLED NURSING
A Pressure Ulcer Pathway must be initiated when the Norton Score is what number
What is 14 or less
But--you may subjectively add this pathway if needed
2 missing meds at SOC.... what do you do?
Call MD and DOCUMENT the outcome.
The HHA care plan requires the following:
Assistive Devices, Emergency Plan, Mobility, Nutrition, Personal Care, Precautions (matching the SOC and including hand hygiene, Psychosocial, Toileting
The initial medication list much match the discharge summary: True or False
TRUE--if there are discrepancies you must document, contact the md and only once you have received a medication update/order can changes can be made to the list