HBC Manual: Admissions

Admission—Initial Nursing Visit

Allergies

Enter Allergies in the box, they will post at the top of the screen to the right of the patient name. If there are dots after the listed allergy, use your mouse to “hover” over the listed allergies and a box will appear with all the allergy details. (This does not currently carry over to PIM and must be entered in PIM as well to appear on the face sheet)

Comments

Enter important (safety) information here that the team should know

Forms

Initial Nursing Assessment
Your hospice may require additional Forms i.e. Safety or Fall Assessment

POC Problems (minimum; Per Agency policy)

Primary Plan of Care OR Knowledge Deficit
Resuscitation
Visit Schedule
CNA Assignment (if applicable)
At least one Care Plan for a symptom/nursing diagnosis

Medications

All routine and prn medications

Orders

Admitting Order (to be signed by either Attending or Hospice Physician)
Physician Certification Statement (this is for the Attending Physician)
Medical Director Certification (this must be completed by the Hospice Physician)
Plan of Care/Comprehensive Assessment Initial (IPOC)
**NOTE** Admitting Orders and IPOC should be done during the same visit as the Initial Nursing Assessment, the initial care plans and the medications. Completing all during the same visit allows the care plans and the medication lists to display on the orders appropriately.
Verbal Certification (no need to print/email)—should be completed by the person who received the Verbal Certification. Does not need to be a nurse; does not need to be signed by the physician.

TIP: As they are completed, orders may need to be emailed to Medical Records/Data entry. When emailing orders to Medical Records/Data Entry, text in all of the patient’s secondary diagnosis/co-morbidities as well as any additional information that is missing in the header (i.e. SSN, Physician, etc.) in the “comments” in the email. This information can then be entered into PIM in a timely manner.