SBAR COMMUNICATION TOOL

Transcription

1 POLICY & PROCEDURE SBAR COMMUNICATION TOOL Date initiated 1/10 Revised Medical Director initial PURPOSE; To assure optimal communication between nurse and physician when there is a significant change in a resident's condition. PROCEDURE: 1. Utilize the SBAR form when a significant change is identified in a resident. 2. Note the onset and history of the symptoms noted. 3. Review the resident's medical background. 4. Complete an evaluation of the resident in regards to the identified concern. 5. Contacthe physician. 6. Document outcome of communication with the physician. 7. Document any pertinent additional information on the back of the SBAR form. 8. File the SBAR in the medical record under "lnterdisciplinary Resident Progress Notes" section.

2 SBAR., N URSHPHYSICIAN COMM UN ICATIONTOOL E PROGRESS NOTE Resfdenf Room Before callinq the phvsician: D Evaluate the resident: Take vital signs, and other appropriate tools: (accucheck, lung sounds, bowel sounds, pedal pulses, etc.) Review chart (recent falls, recent labs, recent nurses' notes, advance directives, etc.) D Have the information available when you callthe physician. S Situation The problem/symptom being reported is related to: _Resp _Gl AMS _Pain _Chg in Fx _Chg in intake _Chg in skin condition _Labs lf applicable: Thisstartedon-andhas:gottenbettergottenworse-stayedthesame. B Backqround This resident's primary diagnosis on admission: The resident's pertinent medical history includes: (Check or write in applicable information)! Allergies: _yes _no lf yes:! Recent fall(s) on n Medication changes recently? lf yes, state: lf pertinent, advancedirectives: A Appearance Vital signs: BP_ T_ P_ R_ Accucheck_ Oxygen sat % on _room air _on via _N/C_mask n Respiratory-lf applicable:_dyspnea _congested_rales_rhonchi_pallor_cyanosis r Gl- lf applicable _nausea_vomited x_ amount_description Bowel sounds-present x_quandrants _diminshed Abdomen _distended _ sofunontender n Change in mental status, lf applicable: _forgetful_confused_agitated_lethargy Other n Pain level lf applicable: Location Scale score_freq uen cy: _constant_interm ittent ochangeinfunction, fapplicab e;-dec ine-improvementin I Change in intake, lf applicable lf alternate nuition recommended, residenufamily wishes: n Ghange in hydration, lf applicable. n Ghange in skin/wound condition: Other things occurring with the resident include: R! n Resuesf (check what nurse is requestinof phvsician) Visit by physician/ar NP New lab/x-ray, othertests Medication changes lv fluids Observe and report Reported to Dr. at_ by _phone _fax _in person by RN/LPN Response by on at_ by _phone _fax _in person received by RN/LPN New orders received include: Responsible party notified of chg in condition on_ at by Documentfufther pertinent information on back of SBAR form.

3 RESTDENI fransfer FORM pase 1 RESIDENT NAME (last, first) SEVf FROM: (Name of Facility) Date DATE OF BIRTH: AGE: Language: renglish nother: Unit- Phone #(-)--- Gontact percon: Currently covered under Medicare Part A in SNF ves no Resident is n Short-term n Lonq-term CONTACT PERSON: Name a HCS o HCP o POA n DPOA n Guardian a Other Phone #(_) Notified of ansfer Jes _no Aware of Diagnosis Jfes _no SENI IO: (name of hospital) Phone #( )_ PHYSICIAN: Dr. Phone *(-)--. Resident has: a DNR (Aftached_yes _no) n Livinq will (Attached ves no) The following are attached: o Face sheet o Current orderc n Bed hold policy o Labs/ X-rays REASOru FOR TRA/VSFER: (Be specific) Route of ansport Ambulance Ambulance service called_ WC van _Car DIAGIVOSES: V/S= BP_ T_P_R_Accucheck_ 02 sat % on _RA_O2 at_l Precautions: o MRSA as of_ n VRE as of_ Site_ n C-Diff as of_ date date date D EVI C E S/ S P ECI A L T REATM ENTS : R/SKALERIS: n lv/pigc/mid-line r Foley catheter n Ostomy n None n Falls n Seizure o Pacemaker n lnternal defibrillator n Aspiration o Elopement a Skin breakdown n TPN Other: a Resaints n Harmfulto self others IMMUNIATIONS: Influenza Given on_ Refused on_ Pneumococcal Given on_ Refused on_ Other Given on Refused on SPECIAL TREATMENTS E FREQ UENCI ES : (lnclude dialysis, chemotherapy, radiation, hospice, etc. here)

4 RES'DENT TRANSFER FORM page 2 USUAL MENTAL SIATUS: n Alert o Forgetful n Disoriented n Can a Cannot follow insuctions U S U AL FU N CTION AL SIA IUS; Ambulates ADLs: r independently l=indep A= Assist D=depen r With assist _Bathing _Dressing n With device _Toilet _Transfer r Non-ambulatory WBS _full _partial _non DIET: n Assist needed n Trouble swallowing n Specialconsistency_ (Ihickened liquids, pureed, crush meds) o Tube feeding Time of last meal CONTINENCE: IMPAIRMENTS: DISABILITIES: lncontinent n Bowel a Bladder n Speech o Hearing n Amputation Currently on reaining yes no n Vision n Sensation u Paralysis Last bowel movement on Other: n Conactures SKIN/WOUNDCARE: High risk for pressure ulcer development yes no Wound progress note attached n yes n no Reddened areas/excoriations: Site Pressure ulcers: (Site, stage, size) Treatment: PAlN:Usua sca e(1-10)-site-presentsca e(1-10)-site Specifics, if applicable: USUAL BEHAVORS EXHIBITED AND INTERVENTIONS (if applicable); SOCI AL SERY'CE I N FO RM ATI O N : Socialworker Phone # Reason for originaladmission to SNF Discharge plan u Return home n LTC n Bed hold Resident o is n is not adjusted to illness Family n is n is not supportive Resident n is a is not self motivated Form completed by: Signature RN/LPN Reoort called to By RN/LPN

5 POLICY & PROCEDURE QI TOOL FOR REVIEW OF ACUTE CARE TRANSFERS Date initiated 1/10 Revised Medical Director initial PURPOSE. To assure medical necessity when residents are ansferred to the hospital. PROCEDURE: 1. Upon a resident's ansfer to the hospital a Ql TOOL FOR REVIEW OF ACUTE CARE TMNSFERS will be completed by the facility's Director of Nurses (DON). 2. All areas will be completed. 3. The DON will determine if the ansfer was avoidable and why the determination was reached. 4. The DON will y to identify any actions the facility can implement to improve management of resident changes in condition. 5. The DON will fax each completed Ql Tool to the Director of Clinical Services at the management company office within a week of the ansfer. 6. The DON will complete a brief summary of the Ql Tool findings for each month for review at each Quality Assurance meeting.

6 QI TOOL FOR REVIEW OF ACUTE CARE TRANSFERS FaCility: (Gircte) Broward Ptantation Springee Tamarac Pinecrest Ocean View Resident name Admission date Resident status at time of ansfer n Long-term nshort-term Pay status: o Medicare n HMO, type- o Medicaid n Private pay Admission diagnosis: Date ansferred to hospital Transfer -was-was not via 91 1 What prompted ansfer to hospital? Physician ordering ansfer: Dr. BP T P_R_PULSE OX-T} (circle) Was resident admitted? Yes/No lf so, admitting Dx What was the residentnstatus at the time of admission reeardinq the reason for discharqe: (For example, if resident is ansferredue to a low hemaglobin, what was the hemaglobin at the time of admission) What interventions did the facility employ in an attempt to prevent the resident from having to return to the hospital? Gheck what applies or write in below. Be Gould this ansfer have been avoided? _Yes -Possibly -No Give reasons below: E There were opportunities to prevenuanticipate with earlier identification and/or management, such as n D The facility was unable to provide necessary care and services: The physi-cian may have kept the resident in the facility if provided with further information/discussion. The resident may not have been ansferred if the physician had returned calls. The facility could have provided further care and services but physician insisted on ansfer -resident or family insisted on ansfer What actions are you implementing to prevent re-hospitalizations as a result of this ansfer? Date- Signature DON