4/15/2015. The Medical Record tells a story. It s a story about the patient s time while in our care

Transcription

1 The Medical Record tells a story It s a story about the patient s time while in our care The story What is written, accurate or incomplete The final account of what occurred with that patient.

2 The story.. The patient s status consistently documented so there is a logical progression from their admission to their current status through discharge The story has three audiences: Other medical professionals Insurers- reimbursement Surveyors or lawyers determining if your care was appropriate Each audience is looking at the record for different reasons, but they are looking at the same information Accurate? Complete? Timely?

3 Patient protection device (Mosby, 2006, p. 4) Quality Management Aid (Mosby, 2006, p. 4) Legal Safety Net (Mosby, 2006, p. 4) If it isn t documented, it isn t done. In order to get reimbursed (Alverzo, 2005) Paramount to the Nursing Process (Alverzo, 2005) A method of communicating with the healthcare team (Alverzo, 2005) TJC specifies that nursing care data related to patient assessments, nursing diagnoses or patient needs, nursing interventions, and patient outcomes are permanently integrated into the medical record The Nurses only and best defense against negligence

4 Source orientated documentation (Mosby, 2006, p. 5) Problem oriented documentation (Mosby, 2006, p. 5) Subjective Objective Assessment Plan Evaluation of patient response Revision as needed based on evaluation Prescreening process Close supervision by MD with specialized training/experience in rehabilitation 24-hour rehabilitation nursing Relatively intense level of services 3 hours of therapy, 5 days a week Require at least two therapies (OT/PT/SLP/orthotics/prosthetics) Significant functional improvement Multidisciplinary approach Coordinated program of care Realistic goals 24- Hour Rehabilitation Nursing Care Elements of specialty practice must be evident: Impact of medical & functional deficits on patient s rehabilitation participation, progress, treatments & education provided Ongoing assessment of effects of treatment (medical & functional) implemented by nursing & other team members Carryover of therapeutic techniques 24 hours per day Self-care Mobility Cognition and swallowing

5 Team approach demonstrated Disciplines actively working together in a coordinated fashion Multidisciplinary Interdisciplinary team approach Communication between & among disciplines Unique contributions of every team member Coordinated program- Team conference Demonstrate a coordinated interdisciplinary approach & team communication Assess progress toward goals Identify barriers/problems to discharge Consider possible resolutions to barriers Reassess validity of current goals Changes to treatment plan and/or goals Progress in measurable terms- increased functionality- related to discharge destination (Should not be a review of FIM numbers) Significant Practical improvement Measured against patient's condition at the start of the rehabilitation program Must be of practical value to the patient Evaluated in the context of the individual s physical impairment and comorbid factors Considering discharge destination Achievable within a reasonable time

6 Realistic Goals Measurable Reflect individual patient circumstance Stated in terms of functional impact Sufficient improvement to allow patient to return home Self-care or independent in ADLs Achieve maximum level of function possible Reflect an interdisciplinary approach Include education/training activities Lack of MD documentation that supports medical necessity of admission & justification for continued rehabilitation Lack of documentation that supports provision of 24-hour rehabilitation nursing services Lack of documentation to support provision of a coordinated program of care that utilizes an interdisciplinary approach Reflect need for specialized rehabilitation nursing Support provision of 24-hour rehabilitation nursing service Knowledge and clinical skills unique to the specialty practice Combination of rehabilitation philosophy & practice with medical-surgical knowledge skills

7 Bowel & bladder management Nutrition & hydration Safety Physical & cognitive components Skin integrity Treatment & prevention ADLs Effects of treatment Carryover and re-demonstration of therapeutic techniques Educational interventions Discharge planning Functional documentation is essential in proving rehabilitation nursing care occurred The way we have always done it Best practice for excellence

8 Summary Note is a description of the patient focusing on the need for specialized rehabilitation nursing Medical, functional, safety, psychosocial conditions, comorbidities Goals, management, & intervention 22 What is your impression of this patient? PT 81 YR OLD MALE RIGHT HANDED WITH LEFT TEMPORAL STROKE. NO C/O PAIN AT THIS TIME. PT VOIDS PRN. FAMILY VERY INVOLED IN HEALTH CARE. Tell the story of a CVA patient and convey medical necessity Bladder Bowel Nutrition Respiratory Medical issues Skin Safety Cognition Functional status Goals 24

9 Age, diagnosis, broad description of impairments Overall mood/presentation and cognitive status Functional and mobility limitations Describing ability to perform self-care Co-morbidities that require ongoing nursing assessment and management Bowel and bladder issues Safety status including level of risk, reasons for safety risk and safety measures implemented Alterations in skin integrity Patient goals based on stated deficits and plan for the delivery of specialized rehabilitation nursing Nursing interventions to be initiated to manage each area must be outlined!!! 25 Individualized - based upon admission assessment Problem, goal, interventions Evaluation of progress Used as a communication toolcontinuity of care Pertinent medical status - effects of comorbid conditions Nursing care & interventions rendered- including teaching/education Follow through with the rehabilitation treatment plan (carryover of therapeutic techniques) Patient function/response/performance Support FIM rating Progress toward goals Barriers Continuity/Communication with team

10 What is your impression of the rehabilitation nursing services that occurred during this shift? Patient resting comfortably in bed, voiced no complaints. Patient ate dinner with spouse. Physician in to see patient, no new orders. Tell the story of the patient s stay Support conditions of participation Treatment decisions, care rendered Patient s progress toward goals status Interventions performed Barriers to goal achievement/discharge Patient s response to treatment Plan of care changes made Justification for continued rehab treatment 29 Tell the story of the patient & convey medical necessity Bladder Bowel Nutrition Respiratory Medical issues Skin Safety Cognition Current status, functional levels, therapeutic carry over, interventions, plan of care, barriers, teaching-education

11 What is your impression of this patient? Foley catheter No complaints of bowel issues Doesn't eat lunch, diabetic Breathing unlabored, alert and responsive Occasional, constant, infrequent headaches Skin pale Reinforced safety Sometimes alert and oriented 31 Admission Summary Note: 87 year old female admitted with complaints of generalized weakness, S/P fall 2 weeks prior with c/o of back and knee pain. Hx: HTN, glaucoma, osteoporosis and hypothyroidism. On admission, patient has impaired gait and debility. Fall score 6 (>2 high risk); alert and oriented x 2 to person and place. Short and long term memory deficits noted. Plan: w/c & bed alarms. On continuous O2 via NC at 2 lpm with weaning orders. Therapy Note Day 8 at 1600: Patient participating in full rehab program; progressing to min assist for some activities but easily fatigued. Ambulated 100 ft with RW with CG. O2 sats 88-89% during rest periods while off O2; applied O2 at 2 lpm via NC during all activities with sats remaining at 93% throughout session.

12 Nursing Discharge Note Day 8 at 2300: Checked on patient at At 2030, heard a loud noise from room; patient laying on floor at foot of bed. Nose bleeding with some deformity, provided compression; bleeding stopped within 5 minutes. Patient complained of leg pain. She states she did not remember how she fell. O2 sats 86-87% without O2 since she was being weaned. VSS. MD notified. 911 called and patient discharged to ER. Addendum: Patient admitted with nasal, periorbital and hip fractures. 65 year old male admitted following MVA with TBI. Has stage II sacral pressure ulcer measured at 1.7 cm x 2 cm. Plan: moisture management, pressure relief with mattress, weight shifts, turning & barrier cream. Nursing Notes: Day 7: Stage II, 1.2 cm x 3.5 cm. Odor absent. Refusing repositioning at times Day 10: Sacral wound stage III, 3.3 cm x 8 cm. Odor moderate. Eating ½ of meals. Refusing Prostat. Day 14: Sacral wound stage II, 3.0 x 8 cm. Day 21: Unstageable pressure ulcer, 3.0 cm x 4.5 cm x 3 cm deep. Refusing pressure relief measures. Day 28: Unstageable black eschar, 3.0 cm x 5 cm x 3.2 cm deep. Wound vac arrived and applied. Drainage moderate purulent.

13 Answers the 6 key questions: Who What Where When Why How The story you write, whether correct or incomplete is the final account.