Agency Forms Medication Profile A complete and comprehensive medication review will be performed by the registered nurse upon admission. The profile must be current at all times; therefore, it is the responsibility of all clinical staff to ensure it is updated with all new (within 30 days), changed (within 60 days), and/or discontinued medications. When any professional, licensed staff is made aware of a medication change, the RN should be notified. Medications directly prescribed by the physician and/or non-physician practitioner (i.e., a new medication bottle or prescription) may be documented on the patient/client visit note and the medication list once the medication is in the home. Medication orders given from physician and/or non-physician practitioner to the clinician or those given to the patient/client and verified by the clinician, will be documented on a verbal order and added to the Medication Profile. Care Coordination Communication Notes Any communication that does not occur during a home visit should be documented on a communication note. Communication between disciplines, with physicians and/or non-physician practitioners, community resources, patient, representative(s), family, significant others, and caregivers should be documented on the communication note. This form assists in documenting the coordination of care and services, between the patient, representative, other disciplines, and physician(s) and/or non-physician practitioner(s) if an order is not required. Progress/Summary/Team Conference Notes This is used to document the care that has been provided as well as the skilled care that will be provided. It documents coordination of care between the disciplines and physician(s) and/or non- physician practitioner(s). The summary describes the events that occurred. This supports the need for continued care. • Prioritize patient/client needs in a chronological order. • Emphasize the need for therapy services or additional disciplines. • Document the homebound status. • Evidence the need for home health aide care. • All disciplines providing care.
