OASIS Alert

Learn the right way to write orders.

How you word orders for your plan of care can determine survey success.

When the physician orders a skilled nursing visit once a week for six weeks, the surveyor will want to see that your agency provided the care the doctor ordered. But unless you use shorthand everyone can understand, you may find the nurse visited more or less often than ordered.

Clinicians use a variety of abbreviations for the same order, says consultant Pam Warmack with Ruston, LA-based Clinic Connections. There is not necessarily only one way to write the order, but you need consistency within your agency.
 
"Have a branch standard for orders," advises Lynn Serra, general manager with Odyssey Health-Care in Rockford, IL.

Back to basics: Three important parts of the order are the discipline, the frequency and the duration, says regional home health intermediary Palmetto GBA in a Web site Question and Answer. Orders can state frequency and duration in days, weeks or months, the RHHI explains. They must include the type of professional who will provide the service, the Centers for Medicare & Medicaid Services instructs in the Medicare Benefit Policy Manual. For example, if the skilled nurse is to visit once a week for four weeks, you can write "SN 1xw x 4w."

Short and Simple Can Trip You Up

For a patient needing daily wound care, you could write "SN 1xd x 21" or "SN 7xw x 3" - meaning daily visits for three weeks. But the person in the field - and the surveyor - may find these orders unclear, Serra says. Here's why:

Example: Imagine it's Wednesday, July 20. The nurse has been visiting this patient three times a week on Monday, Wednesday and Friday. After her Wednesday visit, she notifies the doctor that the wound is not responding well and more frequent visits are necessary. The nurse in the agency who answers the doctor's return call takes the verbal order for daily visits for three weeks.

If she writes "SN 7xw x3," technically the nurse would be expected to complete seven visits in the next three days to comply with that order, because the Medicare week runs from Sunday through Saturday, Serra explains.

One way to clearly convey the information is to write: "3xw x1, beginning July 21" (for the first three days of one week of the order), "7xw x2" (for two full weeks) and "4xw x1" (for the last four days needed to complete three weeks). Even better would be to write "1xd x21, beginning July 21," she says.

Tip: Be sure you have an order for what to do next before this order ends, Serra adds.
 
Avoid These Common Problems

Another problem surveyors often find is staff writing orders that include zero as the frequency, says consultant Susanne Justice-Moran with Ft. Lauderdale, FL-based Justice-Moran & Associates. Even if you're writing an order for a discipline that won't come in until later in the episode, it's incorrect to write an order such as "PT 0xw x1, 3xw x2," she says. Instead, write the order for the visits the PT will make by stating when she will begin. So "PT 3xw x2, beginning July 11" clearly communicates the intent of the doctor's order to the field staff and to surveyors. Other common problems include: