Tag Archives: plan of care

The Most Important Document

Charting

Home Healthcare Documents
Form CMS-485 (Plan of Care)
“The Most Important Document”

Home Health is known for its plethora of documents, but one form stands out amongst them all: the “Plan of Care” also called the “485” after its Center for Medicare/Medicaid Services document No. CMS- 485.

This document is so important because it is the so called “Mother Document.” Plans of Care combine the orders of multiple medical disciplines into one document. This comprehensive authoritative Document governs many of the forms in the home chart and the actions of the nurses providing care. Each 485 contains the Patient and Provider demographics, Medication orders, Nursing orders, Diagnosis/Procedure Codes, Supply lists, Nutritional requirements, Allergy info, Patient Activities/Limitations, Ancillary care orders (OT,PT, etc.), Goals and Discharge plans, and a Penalty statement for falsification, misrepresentation or concealment of essential information on the form.

According to CMS rules the Patient must be evaluated and the Nurses supervised and orders rewritten at least every sixty days. All Therapies and medications listed become Doctors Orders once signed. All other documents (i.e., Medication Administration Record) in the home chart should follow the orders listed on the 485, except interim orders written/signed after the date of the 485. The 485 should be the “Go To” document when unsure, or verification of Rx/Tx’s is needed.

Keeping the 485 updated and accurate, is the responsibility of all Care Providers utilizing it as a fiduciary document to authorize their professional services. The 485 is edited by the Nursing Supervisor and endorsed by the Doctor every 60 days, but in-between that period the plan is adjusted and tuned to match the Patients dynamic condition. Medications are changed, diets are adjusted or therapies may be started. When these interim alterations occur, it is each caregiver’s responsibility to verify if needed and pass on to the Nursing Supervisor proof of such changes in a timely manner so the 485 will be accurate the next certification period. Verification can be done via phone calls/faxes and Verbal/Telephone (VO/TO) orders forms. Clear, timely and accurate communication is the best prophylactic therapy professional caregivers can administer. Consistently checking the 485 and interim orders w/ timely communication is the bridge to good continuity of care. All interim order copies should be kept with or near the 485 for reconciliation by all caregivers.

Utilizing and maintaining the Plan of Care CMS- 485 is serious business, not to be taken lightly. Let me quote the responsibilities charged in the Illinois Nurse Practice Act: “The administration of medications and treatments as prescribed by Physician…a Dentist…Podiatrist…Optometrist…PA…APN. The coordination and management of the Nursing Plan of Care.”

Please pay attention to this important document and communicate with your Nursing Supervisor. Your Patient, his/her PMD and your fellow caregivers will love you for it.

by Shawn A. Pickett, MSN, RN

First published on American Home Health's Newsletter, December 2008.