Policy Manual sample

MDT Home Health Care Agency, Inc. PROCEDURE FOR 60 DAY SUMMARIES Purpose: Informs physician of patient status, progress, deterioration within the previous 60 days period (certification or re-certification period), request by State Regulatory Agency, CMS, or intermediaries. Definition: A brief summary which documents patients condition/status within the previous 60 day period. Summary needs to be done only for those pt’s which will be recertified. Patients who have been discharged after a certification period (episode), do not need a 60 day summary (all summaries of conditions/status must be done in the Discharge summary documentation and faxed to Patient’s physician). Procedures: I. Upon patient's recertification, field clinical personnel will provide tthe Agency ( and them faxed to the physician), with a brief summary of patient status for the previous 60 day period. II. Upon completion of recertification and 60 day summary, routing will occur as follows: A. System Data Entry for typing and printing, or Field employee may hand write the summary directly in the appropriate 60 day summary form. B. Returned to Q.A. personnel for proofing. C. Signed by clinical field employee. D. Given to Medical Record for logging and mailing or faxing. E. The document will be couriered, faxed or mailed to corresponding M.D. F. Copy of both the recertification and 60 day summary will be sent to medical records to be filed in the chart. KEY POINTS: a) Do not include orders in the summary, they are already on POC (485) and/or Recert-Modify Orders. b) Summary should always be attached to the recertification and should be mailed/faxed with the recertification. c) Wound Care, include last measurement, progression/deterioration, (size, odor, drainage, etc), treatment given provided. d) Foley patients, include last date change, size, if patient continues require foley catheter, emergency visits made due to leaking, accidental removal, etc. e) Hospitalizations, dates, new medications or diagnosis. f) Briefly document vital signs in ranges for that period, and brief assessment. Home Health Agency Nursing Care & Procedures K-105