Caregivers who need to submit a 485 on behalf of their clients can generate the form directly in AlayaCare. When creating the 485, data from the client's profile will automatically populate the form to avoid having to reenter information.
The following sections of a client's profile are linked to the 485:
- Demographics
- Coordination
- Medical History
- Medication
- Care Plan (1.0 or 2.0)
- Risk Assessment
- Equipment and Supplies
- Care Item Descriptions
The 485 itself can be added and approved from Document Approval in the Care Documentation tab on the client's profile:
Enter the Client's Demographics
The First and Last Name, Address, Phone Number, Sex, and Date of Birth entered in the Demographics tab on the client's profile appears in the Patient's Name and Address, Date of Birth, and Sex sections (6,8, and 9) of the 485.
Enter the Client's Physician as a Contact in the Coordination Tab
To have the contact information of the client's physician appear on the 485, you must first enter the physician as a client contact in the Coordination tab of the Client's profile.
Click Contacts in the Coordination tab and click +Add New Contact.
Enter the physician's name, address, and phone number and then save the contact. You will now be able to select the client's physician from the Physician dropdown when adding a 485. The contact information for the physician will appear on the 485 in the Physician's Name and Address section (24).
Learn more about adding client contacts.
Complete the Client's Medical History
Information about a client's Diagnoses, Surgeries, Nutritional Requirements, Functional Limitations, Activities Permitted, Mental Status, or Prognosis entered in Care Documentation>Medical History on the client's profile will be automatically added to a 485 created for the client.
The diagnosis marked as the client's Primary Diagnosis will appear as the Client's Principal Diagnosis on the 485 (section 11). The rest of the Diagnoses entered in the Client's Medical History will appear in the Other Pertinent Diagnoses section (13) of the 485.
Surgeries entered in the Client's Medical History will appear in the Surgical Procedures section (12) of the 485.
In Medical History:
On 485:
Any Nutritional Requirements, Functional Limitations, Activities Permitted, Mental Status options, or Prognosis options checked in the client's Medical History will appear in the corresponding sections (16, 18.A, 18.B, 19, and 20) of the 485.
In Medical History:
On the 485:
Learn more about completing a client's medical history.
Enter the Client's Medications
Active Medications that have been entered in Care Documentation>Medication on the client's profile will appear in the Medications section (10) of the 485. The Medication Name, Dose and Dose Type, Time Instruction, and Route will be included for each medication.
In Medication tab:
On the 485:
If a medication has been added since the last 485 was generated for the client, it will be marked N for new on the 485. If a medication has been modified since the last 485, it will be marked C for changed. If it is the first 485 added for the client, all medications on the form will be marked as new.
Fill Out the Client's Care Plan (Care Plan 2.0)
If your organization is using Care Plan 2.0, active diagnoses, interventions, and goals on the client's current active care plan will flow through to the 485.
Active diagnoses and interventions will appear in the Orders for Discipline and Treatments section (21) of the 485. If an intervention is linked to a diagnosis on the care plan, it will appear under that diagnosis. Diagnoses and their linked interventions will appear in the order the diagnoses appear on the care plan.
In the care plan:
In the 485:
All diagnoses will flow through to the the 485, unless they have been archived or resolved.
You can control which interventions appear in the 485 by using the Include in 485 checkbox when adding or editing an intervention. When adding an intervention, the Include in 485 checkbox will be selected by default. If you do not want that item to pull through to the 485, uncheck the box.
Interventions that will be included in the 485 will have the 485 icon next to them in the client's care plan.
The client's active goals from the care plan will appear in the Goals/Rehabilitation/Potential Discharge Plans section (22) of the 485. Goals will be listed in the order in which the diagnoses they are linked to appear in the care plan.
In the care plan:
In the 485:
Learn more about adding and editing diagnoses, interventions, and goals.
Complete the Client's Care Plan (Care Plan 1.0)
If your organization is using Care Plan 1.0, nursing diagnoses, interventions, and goals added to a client's care plan will automatically appear on the 485.
Nursing Diagnoses and Interventions will appear in the Orders for Discipline and Treatments section (21) of the 485. Note that each Diagnosis must be numbered 1, 2, 3, etc. when entered on the care plan. Each intervention must be numbered 1a, 1b, 2a., etc. to represent which diagnosis it is related to. In the 485, the interventions will be listed in order after the linked diagnosis.
In the care plan:
In the 485:
Nursing Goals and Client Goals from the care plan will appear in the Goals/Rehabilitation/Potential Discharge Plans section (22) of the 485. Goals should be numbered 1, 2, etc. according to which diagnosis they are linked to.
In the care plan:
In the 485:
When adding Nursing Diagnoses, Nursing Interventions, or Nursing Goals to a client's care plan, you can click +Add Item and type in the item yourself or Select a Library to choose them from.
Learn more about completing a Client's Care Plan.
Add Risks to a Client's Risk Assessment
Any Allergies added as Risks to Risk Assessment in the Overview tab of the Client's profile will appear in the Allergies section (17) of the 485. Any Risks in the General, Environmental, or Infectious Diseases categories added for the Client will appear in the Safety Measures section of the 485.
In Risk Assessment:
On the 485:
Learn more about adding risks for a client.
Add a Provider Requisition to the Client's Equipment & Supplies
Equipment and Supplies added to a client's profile will appear in the DME and Supplies section (14) of the 485.
To have items appear in this section of the 485, you must first add and approve a Provider Requisition for one of the client's services. To do so, go to the Services tab on the client's profile, select a service (by clicking the service name), and go to the Equipment & Supplies tab. From here, click +New Requisition.
In the dialogue box, select Provider Requisition in the Delivery or Pickup field and then click Save.
After creating the Provider Requisition, start adding items by clicking +Add Item.
In the Item Name field, you can either type them name yourself or start typing to select an item from the list of Supplies in Clients>Supplies Management>Provider Catalogue.
Enter a Quantity and any Additional Information and then click Save.
You must approve the Provider Requisition before the added items will appear when on a 485. Click the Approve button on the Requisition to change the status from Draft to Approved.
In Equipment & Supplies:
On the 485:
Learn more about managing Equipment and Supplies.
Displaying Descriptions to Care Item Fields in the 485
Agencies that have multilingual caregivers have been recommended to put translated material into the description field of the "goal", "diagnosis" or "intervention", as translation for this particular field is not currently supported by our localized Spanish or French versions.
Users can now navigate to System Settings and choose to turn the descriptions to these care items ON or OFF within the 485. Settings can be toggled like the sample shown below.
Add the 485 in Document Approval
When you are sure that the relevant information in the client's profile is correct and up to date, you can go ahead and generate the 485 for the client by going to Care Documentation>Document Approval and clicking +Add 485 Form.
In the resulting dialogue box, enter the Client's HI Claim No., Provider No., Certification Start Date, Certification End Date, and Start of Care Date. In the Physician dropdown, select the Client's Physician from their list of contacts. This information will appear directly on the 485.
When you have finished, click Save.
The document will appear as a Draft in the Document Approval screen. Note that the information in the Provider's Name, Address and Telephone Number section (7) is pulled from Settings>Agency Information.
Sign the Form and Mark as Sent
After reviewing the generated form, click Send to mark the 485 as sent.
In the dialogue box, enter the Date of Verbal SOC (if applicable) and use your cursor to sign your name electronically in the Signature field. When you have finished, click Mark As Sent.
Your electronic signature will appear in the Nurse's Signature and Date of Verbal SOC Where Applicable field (23).
If you discover an error in the form, click Reject. After marking the form as Rejected, you can correct the errors and add a new 485 for the client.
Approve the Form
Once the 485 Form has been signed by the client's physician, you can upload the signed form and mark it as Approved. To begin, click Approve on the 485 Form.
Click Upload file here to attach a scan of the signed 485 Form. After attaching the document, click Approve.
The Status of the 485 Form will change to Approved.
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