Or. Admin. Code § 410-132-0070 - Documentation Requirements
(1)
Documentation of services provided shall be maintained in the client's place of
residence by the private duty nurse until discharged from service. Payment may
not be made for services where the documentation does not support the
definition of skilled nursing. Documentation shall meet the standards of the
Oregon State Board of Nursing.
(2)
The private duty nurse shall ensure completion and documentation of a
comprehensive assessment of the client's capabilities and needs for nursing
services within seven days of admission. Comprehensive assessments shall be
updated and submitted to the responsible unit by the next work day after any
significant change of condition and reviewed by the responsible unit within the
Oregon Health Authority at least every 60 days. Some examples of significant
change in condition are hospital admission, emergency room visit, and change in
status, death, or discharge from care.
(3) The nursing care plan shall document that
the private duty nurse, through case management and coordination with all
interdisciplinary staff and agencies, provides services to attain or maintain
the highest practicable physical, mental, and psychosocial well-being of each
client in accordance with a written, dated, nursing care plan. The nursing care
plan shall:
(a) Be completed within seven
days after admission for children and adolescents with short-term needs who are
served through the Division. The nursing care plan shall be reviewed, updated,
and submitted whenever the client's needs change, but at least every 60 days;
(b) Describe the medical, nursing,
and psychosocial needs of the client and how the private duty nurse will
actively coordinate and facilitate meeting those needs. This description of
needs shall include interventions, measurable objectives, goals, and time
frames in which the goals and objectives will be met and by whom;
(c) Include the rehabilitation potential
including functional limitations related to Activities of Daily Living (ADL),
types and frequency of therapies, and activity limitations per physician order;
(d) Include services related to
school-based care according to the IEP and the Individualized Family Service
Plan, if applicable;
(e) Show
coordination of all services being provided including, but not limited to, the
client or representative, registered nurse (RN) case manager, Department case
worker, physician, other disciplines involved, and all other care providers
involved in the client's treatment plan;
(f) Include a statement of the client's
potential toward discharge. Timelines shall be included in the plan outline;
(g) Be available to and followed
by all caregivers involved with the client's care.
(4) Documentation of private duty shift care
and responses to care shall be written in an accurate, timely, thorough, and
clear manner on the narrative or flow sheet. Documentation shall comply with
the requirements of the Oregon State Board of Nursing in OAR chapter 851 and
shall include:
(a) The name of the client on
each page of documentation;
(b)
The date of service;
(c) Time of
start and end of service delivery by each caregiver;
(d) Anything unusual from the standard plan
of care shall be expanded on the narrative;
(e) Interventions;
(f) Outcomes including the client's response
to services delivered;
(g) Nursing
assessment of the client's status and any changes in that status per each
working shift; and
(h) Full
signature of provider.
(5) Documentation of delegation, teaching,
and assignment shall be in accordance with the Oregon State Board of Nursing
Rules.
(6) For documentation to be
submitted with prior authorization, see OAR
410-132-0100.
Notes
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
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