What is a Visiting Nursing Directive in Japan?
How to describe it and what to do if you can't get it 

Supervisor: Tomoya Hirota 
English translation of  What is a Visiting Nursing Directive? How to write it down and what to do if you don't get it | Medical Japan

Home-visit nursing involves a nurse visiting a patient’s home to provide care. In Japan, where the population is steadily aging, the role of home-visit nursing is expanding and has become an essential support for home medical care.

A home-visit nursing instruction issued by the patient's attending physician is necessary to provide this home-visit nursing to the patient. In this article, we will explain the types of home-visit nursing instructions in Japan and the items that are listed.

A home-visit nursing instruction is a document issued to a home-visit nursing station when the attending physician, after examining a patient, determines the need for home-visit nursing. Without this instruction, home-visit nursing cannot be provided.

The information included in the home-visit nursing instruction includes the following items:

• Period of home-visit nursing instruction
• Name of major injury or illness
• Medical condition/treatment condition
• Dose and dosage of the drug being administered
• Information on pressure ulcers
• Information on medical devices worn and used
• Precautions for medical treatment and lifestyle guidance
• Information on rehabilitation
• Contact information in case of emergency, response in case of absence
• Name of doctor, name of medical institution

There are four types of home-visit nursing instructions depending on the content of the nursing care. The names of each instruction are as follows:

• Home-visit nursing instructions
• Special home-visit nursing instructions
• Home-based patients visit IV injection instructions
• Psychiatric home-visit nursing instructions

A home-visit nursing instruction is a form issued by a designated home-visit nursing service provider, such as a home-visit nursing station, to receive guidance from the attending physician when providing home-visit nursing or rehabilitation for a patient in home medical care.

The home-visit nursing instructions include basic patient information, the name of the disease, treatment status, and any necessary procedures the visiting nurse must know. Home-visit nursing can be covered by both long-term care insurance and medical insurance, but in both cases, it is required that "instructions from the attending physician must be received in writing." The instruction period can be set for up to six months.

The characteristics of the visit performed in the home nursing instruction are as follows:

• Once a day
• The visit time per visit is 30 minutes to less than 90 minutes
• Can be carried out up to 3 times a week
• One nurse responds from one visiting nursing station

A special home-visit nursing instruction is issued when the attending physician deems it necessary to provide frequent home-visit nursing care temporarily, based on medical treatment for conditions such as acute exacerbation (sudden deterioration of symptoms), terminal life, or immediately after discharge. The instruction period can be set for up to 14 days. Typically, it can be issued only once a month, but in the case of severe pressure ulcers, it may be issued twice a month.

By having a special home-visit nursing order, you can respond as follows:

• Multiple visits per day
• Can be conducted more than 4 days a week
• Visits exceeding 90 minutes can be made once a week
• Multiple nurses can respond from multiple designated visiting offices (home-visit nursing stations, etc.)

A home patient visit infusion instruction is issued when the attending physician determines that intravenous drip treatment is necessary at least three times a week. The instruction period is seven days, and it can be issued weekly if needed. Additionally, the instruction can be issued as many times as necessary within a month, with each period lasting up to seven days. 

A psychiatric home-visit nursing instruction is issued by the attending psychiatrist when it is determined that psychiatric home-visit nursing is necessary. This instruction can only be issued by a psychiatrist and allows visits by mental health social workers and public health nurses, in addition to nurses. It should be noted that this instruction cannot be issued alongside the home-visit nursing order. The instruction period can be set for up to 14 days. 

This section describes the instruction period for the home-visit nursing order. The instruction period can be set between one and six months. If a period exceeding 6 months is entered, the home-visit nursing order will be considered invalid. If no period is entered, the default instruction period will be one month from the date of issuance.

This section specifies the instruction period for intravenous drip injections, which is limited to a maximum of one week.

This section indicates the patient's primary condition. It is important to carefully check whether home-visit nursing is covered by medical insurance or long-term care insurance.

This section describes the patient's current situation. It is critical for ensuring appropriate home-visit nursing, so it must be read and understood carefully. It includes detailed information about the patient's symptoms, medications, dosages, and methods of administration.

The status section is divided into the following subsections:

• Medical Condition and Treatment Status: Description format
• Dosage and Dosage of the Medication During Administration: Numbered 1-6 as necessary
• Degree of Independence in Daily Life (degree of bedriddenness, dementia status): Enclose the relevant items in circles
• Status of Certification of the Need for Long-Term Care: Circle the relevant items
• Depth of Pressure Ulcers: Circle the relevant items
• Medical Devices Worn/Used: Enclose the relevant items in circles (there are specific entry points)

This section outlines important considerations to be aware of when receiving home-visit nursing. Include information related to daily activities, such as eating, bathing, excretion, level of activity, and rest. Visiting nursing services will be provided based on the information in this section, so be sure to check all necessary items.

These are items that provide instructions for intravenous drip treatment to be administered to patients in home nursing care. Include details such as the type and dosage of the infusion, the rate of administration, the method of administration, the frequency and timing of administration, the infusion route, and any other relevant information. The nurse will administer the infusion based on these instructions.

These are items that must be considered when using a home-visit nursing service, such as important details about drug interactions, side effects, and a history of drug allergies. Requests regarding the number of nurses needed may also be included, such as, "I have strong muscle tension and contractures, so it is anticipated that one nurse may not be sufficient to provide care." 

In some cases, you may not be able to receive home-visit nursing instruction from your doctor. We will explain what steps to take in such situations and how to proceed to have home-visit nursing instruction issued. 

If the consent of the attending physician is not obtained, the home-visit nursing instruction will not be issued. Therefore, it is essential to obtain the attending physician's consent for the use of home-visit nursing in order to have the instructions issued.

If the patient finds it difficult to explain their situation to the attending physician, a document outlining the need for home-visit nursing can be prepared by the visiting nursing station and provided to the doctor by the patient. It may be easier to obtain the attending physician's consent by having the nursing office or the care manager explain the necessity of home-visit nursing. One way to do this is to obtain the patient's consent and share the home situation with the attending physician via fax or other means.

In some cases, the attending physician only knows the patient's condition when he or she comes to the clinic for treatment. In addition to telling the patient what kind of situation they are in in their daily life and what benefits they will receive from receiving home visits and nursing, it can be useful to convey specific instructions that you want them to give you so that they understand the need.

If you are still unable to obtain consent to issue a home-visit nursing order, it is a good idea to consider using a second opinion from a doctor who is not your primary care physician.

So far, we have explained the characteristics of the four types of instructions and the items described in the instructions for home-visit nursing for patients. Please refer to the points explained in this article so that patients who need home-visit nursing can receive services smoothly. 

What I try to keep in mind when creating a home-visit nursing instruction is to provide concise, easy-to-understand, and accurate information without making it too long, as well as describing it so that you can understand your current medical condition.

We also try to clearly describe the details of treatments, intravenous drips, oral treatments, etc., so that there is no miscommunication. In addition, I try to write content that considers possible situations that may occur in the future in the note's column.

What I would like the visiting nurse who receives the instruction to keep in mind is that if there is a change in medical condition or change in life, please report it to the medical institution that issued the instruction. I hope that we will be able to build a foundation of cooperation together that will allow us to take immediate action. If multiple medical institutions are intervening, I think that clarifying the reporting destination will allow us to respond to sudden changes without delay.