Demystifying the 485 poc.pptxb

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  • MAY ACCEPT ORDERS FROM THE FOLLOWING PHYSICIANS AND THEIR MD COLLEAGUES:PCP /Pediatrician: _____________/Ph_______________ ( list all MD on case )Pulmonologist: _____________/Ph_______________Neurologist: _____________/Ph_______________Gastroenterologist: _____________/Ph_______________Orthopedic: _____________/Ph_______________Nephrologist: _____________/Ph_______________
  • VITAL SIGNS: Obtain vital signs per shift and as needed per nurse / caregiver discretion. Vital Signs to be evaluated include Pulse, Respiratory rate and Temperature (tympanic; temporal or axillary), blood pressure as needed per nurse / caregiver discretion VITAL SIGN PARAMETERS: Report vital sign values outside the following parameters to the MD and EPIC RN Supervisor if not resolved by ordered interventions:
  • Who is this client and why are we providing servicesEveryone who reads this POC should be able to discern that with a brief Admission summary added to POC
  • *educate field staff on importance of reading the 485 and implementing it*Educate them on let you know when inaccuracies and inconsistency are noted
  • * Checksupplementals orders against 485 to make sure they where transcribed
  • Demystifying the 485 poc.pptxb

    1. 1. Demystifying the 485/POC Tammy Marie Baker RN DOCS
    2. 2. Learning Objectives After completing this module the learner will have better understanding of:  Purpose and Review of POC/485  Purpose /use of each locator box within the 485  Archiving the 485 2  Tracking orders  Identifying appropriate orders for individual patient needs
    3. 3. Locator Box # 1 Patient Insurance ID #  Generates from EMR or Manually Entered  Patients Insurance ID number Audit trend:  Missing
    4. 4. Locator Box # 2 Start of Care SOC :Start of Care Date you provide first Billable service Date will remain the same as long as the patient has stayed active Audit trend:  Wrong date/billing errors  Dating errors
    5. 5. Locator # 3 Certification Period:  60 Calendar Days  From Date= Begins with original cert date  To Date: = last date of the POC “the 60th Day”  Recertification Date will start after the 60th day  Recertification date is one day forward from day 60. ie: if cert date ends on June 1st then the first date of the recert will begin June 2nd Audit trend:  Overlapping dates  Not moving recert date one day forward  Dates not changed at all
    6. 6. Locator # 4 Medical Record # Generates from the EMR system If a Client is discharging and then readmitting an alphabet letter should be added to the origonal number MR number should be used on nurses notes Audit trend:  Missing on nurses notes  Not changed on readmissions
    7. 7. Locator # 5 Provider number Corporate to enter when the branch data base is created Audit trend:  Missing
    8. 8. Locator Box # 6   Patient’s name, address and phone numbers Entered by branch upon admission Audit trend:  Missing phone numbers  Client moved / address not updated
    9. 9. Locator # 7 Providers name, address and telephone number Tech support to enter when the branch data base is created *NOTE: If your branch moves, Addresws needs to be updated by IT department for accuracy and billing Audit trend:  Not updated when branch moves
    10. 10. Locator Box # 8  Date of birth  Check on admission Audit trend:  Incorrectly entered years
    11. 11. Locator # 9  Patients Gender  Entered by Branch upon admission Audit trend:  Wrong gender entered
    12. 12. Locator # 10 Medications: Include concentration / dosage / frequency /and route Parenthesis around your ( concentration) will make it stand out SELECT ROUTINE OR PRN Use Sort box to organize the order in which they appear Include PRN indication “why” and parameters duration/frequency”as ordered Include OTC meds such as Vitamins ointments; pain relievers Remember Oxygen is a medication Audit trend:  Missing Concentrations Enter an “N” for medications that are new within the last 30 days  Missing date of start  Routine of prn not selected Enter “C” for changed medications in the past 60 days  PRNS’s missing reason and duration  OTC excluded from Med profile  Missing verbal orders never made it to Med Enter “R” for medications renewed Profile  Reconciliation not completed at visits and Enter “O” for ongoing medications meds not accurate to home MARS to 485
    13. 13. Locator # 11 Principal Diagnosis: The ICD9 code that best describes the principal reason for home health services + Add Date of onset The most acute condition Do not use V codes as primary diagnosis When entering the ICD9 code Note that the medications should correlate to the diagnosis.  Example: client is on Albuterol and Zopenex there fore Patient should have a Respiratory Diagnosis Note; a change in medications associated with this diagnosis could signify an exacerbation Audit trend:  ICD 9 code is not the primary reason for service  V Codes as primary Diagnosis( wrong  )  Diagnosis don’t match or reflect prescribed meds  Date of onset missing
    14. 14. Locator # 12  Surgical Procedures Such as GT/ VP shunt/ ostomy ect..  May Use V codes here Audit trend:  Missing GT or trach status  Missing procedure codes here but discussed latter in box 21 of 485
    15. 15. Locator # 13 Other Pertinent Diagnoses: Place in order of seriousness Most important Diagnosis entered first  Justifies the discipline and services being rendered  Note that “ All medication’s ”should tie into a diagnosis code Audit trend:  Missing ICD 9 codes  Codes not updated to current condition
    16. 16. Locator # 14 DME: ( Durable Medical Equipment ) Current Durable Medical Supplies List all equipment in the home related to the care of the client Equipment maybe in other areas of the home (scavenger hunt ) Ask the family what Medical Equipment they are using. Separate Equipment listed with a Semi colon : or a / (see sample ) DME: Apria (800)543-7123 Nebulizer/Neb sets/ Suction portable/ suction regular/ Pulse ox/ Pulse ox probes/oxygen/ o2 concentrator /wheel chair/AFO’s/ stander/ cough assist. Audit trend:  Missing DME Provider name and number  Missing DME and latter stated in body of 485
    17. 17. Locator Box #15 Safety Measures: These can be physician ordered or identified upon admission. See Examples:  Universal Precautions  Seizure Precautions  Falls Precautions  Sharps Precaution  Toddler Precautions  Safety Precautions  Immune suppression Precautions  Anaphylaxis Precautions Audit trend:  Missing measures pertinent to the patient condition
    18. 18. Locator Box # 16 Nutritional Requirements: Type of formula /(KCAL/ML) DOSE /FREQUENCY/ ROUTE Method of Administration : pump/ bolus Nutritional Risk (high, med, low) Audit trends: GT FEEDS AND/ OR FLUSH DOES NOT MATCH NURSING DOCUMENTATION Flushes/ free water : Dose/freguency Example: Elocare Jr 1.5 (Kcal/ml) give 220 ml with 120 water qid via GT(8am/12pm/4pm/8pm) *Flushes 10 ml water pre/post meds and feeds **Free water (restricted/ unrestricted) _____ml/day
    19. 19. Locator Box # 17 Allergies: NKDA or NKA if none List All allergies Seasonal and environmental as well Audit trend:  comprehensive assessment or written medication profile list allergies not transcribed on the 485  Missing Seasonal / Environmental Allergies  Epi Pen in meds and no allergies listed?
    20. 20. Locator # 18 A & B Functional Limitations: As assessed by physician and/or the agency Write ins can be added such as communication impaired/blind/deaf/assist all ADLS/ assist all ADLS ect... Verify what is documented on the assessment, Oasis, PRIF to ensure transcription onto the 485 Audit trend:  Communication Impaired
    21. 21. Locator # 19 Mental Status: 1.List All allergies select a status 2. May use add : Locked in/infant / Oriented x person only ect..... Audit trend:  Missing
    22. 22. Locator # 20 Prognosis: select choice appropriate to Patient outcome:  Poor  Guarded  Fair  Good  Exellant Audit trend:  Missing
    23. 23. Locator # 21 Orders of Discipline & treatments: Skill Level/ Hours/Frequency and Duration of services provided x 60 days: SN RN/LPN____hrs/day x ____days/week x 60 days. matches the current authorization May use a flex order 8-16 hours per day x 5-7 days/week ( this covers gaps in services) Services provided Clear order sets Use good clinical judgment for clear, concise and complete orders, Specify Equipment name/ size of tubing's/ settings on equipment / duration/ frequency and when to use apnea monitor List the skilled order sets in head to toe format. Audit trends  Frequency and duration does not match authorization  Incomplete order sets  Wrong GT size, wound orders, IV orders  Wrong ventilator, oximeter or apnea monitor and/or missing frequency of use
    24. 24. Box 21 Locator continued: Audit Trends:  Ancillary MD on case not included  Pain assessment /treatment missing  Times/duration and frequency's omitted  List emergency Contact number:  List All Physician  Vital signs : time/frequency with age appropriate parameters  Pain Assessment  Head to Toe assessment with Systems: Pain /Neuro/Cardiovascular/Respiratory/Gastrointestinal/Genitourinary/Integumentry/Musculoskeletal/Psych-Social  Nursing Diagnosis per system  All treatments listed per system  All parameter Time/duration/ frequency per medical treatment
    25. 25. Vital Additions to the POC : Patient Education: must be addressed and pertinent to Diagnosis Communication Impairment: How can SN/PCG facilitate clients communication Safety: Pediatric/Toddler /Falls/Elderly Care Coordination: Case managers; MD appointments; school; therapist ect. Discharge Planning: Begins at admission and continues through out care Audit Trends: missing key pieces :  Patient Education not noted  Communication impairment not addressed  Care Coordination
    26. 26. Admission Summary *Insert a brief admission summary into the 485 history at the bottom of your box 21 section. ( Who is this client and why are they under services) History of patients Illness Birth/gestation Reason for Admission PMH: ( Past medical History ) Snap shot picture of your client Audit Trends:  Admission summary missing  Who is this patient? Inquiring clinicians want to know?
    27. 27. Recertification Process  Verify frequency and duration against current authorization  Requires a Complete reassessment of the client  Check all supplemental orders in the past 60 days to verify transcription and include in the 60 day summary  Revise the 485/POC to Include all updates/ changes documented in the patient record over the past 60 days  60 DAY SUMMARY: summation of what occurred with your client in the past 60 days. Written at bottom of 485 post reassesment.  Call MD with updates for RSOC Audit trends:     Updated orders are not included Goals are not updated Summary is incomplete Frequency and duration does not match the current authorization
    28. 28. Locator Box # 22 GOALS: Match your goals to the Diagnosis / treatment/ services provided per locator #21.  Update the goals with each recertification  Individualized  Measurable  As evidenced by  Timeframes Discharge planning to be addressed Rehabilitation to be addresses Admission summary: Mention all systems in head to toe format and give details on those systems in which we are providing services  Please Don’t forget to include psychosocial and care coordination in the goals sets. ( Holistic Nursing Care ) . Audit Trends  Goals not updated or patient specific  Not evidenced based  Psych needs / care coordination omitted
    29. 29. Locator Box # 23 Nurses Signature and Date of Verbal Start of Care: Initial POC is dated on SOC This is the Date you received orders for homecare services  Subsequent POCS are Dated on date reassessment was done and Updates called to MD VSOC for RSOC: Verbal start of care for Recertification (verbal orders for recertification from the physician.) MD must agree to recertification and sign off on POC Audit Trends:  Incorrect date,  missing signature
    30. 30. Locator Box # 24     Physician’s name, address and phone number Generate from EMR once MD is put into the system ALL MD’s must be verified for licensure status on line Check Phone and Fax numbers for accuracy Audit Trends:  MD not verifed  Wrong primary Physician
    31. 31. Locator Box # 25 Date HHA received signed POC  Stamp or sign and date POC on Date it is received from MD office returned with MD signature It is recommended that the agencies date every plan of care upon return from the physician Audit Trend: This is a  missed item which auditors will access.  Date Received not stamped
    32. 32. Locator Box# 26 Physician Certification Statement: No entry needed Acknowledgement for signing physician Audit trend:  n/a
    33. 33. Locator Box # 27 Attending Physician’s Signature and Date Signed: Time frames State Specific No rubber stamps No Nurse Practitioners or PA’s May accept faxed copies save the original for clarity Do not date the physicians signature if S/he did not date, go to box 25 Audit Trends:  Stamped signature  Not dated  Late
    34. 34. Archiving the 485 Archive every 485 upon admission & recertification in the EMR system of usage: This saves every version / recert of the plan. Click the Archive Tab Click the Archive Tab Click the Physician sign of date and enter date Save the current Plan of care prior to day 56/60b revision for next cert This will keep a permanent record of all certification periods Can also view previous archived 485’s in this area Audit Trends:  Inconsistency in Archiving  Missing 485/POC
    35. 35. Miscellanies  The 485 must be entered into order tracking  All 485’s are Archived after MD signs and prior to revisions on next certification period  485 = First Page/487 = All pages after  Maintain a copy of the original 485 in the active patient chart and a signed Md copy both home chart and office chart  Proof reading the 485 us essential and should be done x 2 clinicians prior to sending to the physicians Audit trend:  Missing copies in the home
    36. 36. Following 485/ Physician’s orders: Nurses should be educated on the POC/485 and review it with their CS or DON prior to all cases: When educating our nurses we need to ensure that they clearly understand The 485 is the physician’s order The 485/ physician’s order is what governs their practice. We are NOT to alter the 485/ physician’s without a confirmed physician’s order We are never to take an order from a parent. If a parent asks you to omit and/or do something that is not supported or in agreement by the 485/ physicians order you must notify the physician immediately Audit trend:  Insufficient training on 485
    37. 37. Reviewing orders for Accuracy/ Consistancy  The 485/ physician’s order should be reviewed by every nurse providing care to client as it is the physicians orders and clients POC  Accuracy should be reviewed for errors  Is it Appropriate and does it meet Client/ patient’s need  Accurate Clearly and thoroughly written  Clinician writing the POC should proof read it prior to signing and faxing to MD  The physician shall be notified for any inaccurate, unclear or incomplete orders Thanks everyone for participating in this tutorial Tammy Marie Baker, RN

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