Sample Observational Report

Transcription

1 Sample Observatinal Reprt The Observatinal Reprt summarizes, in utline frm, the ntes yu tk while Shadwing a patient and family thrughut their Care Experience. It is helpful t write yur Observatinal Reprt as sn after Shadwing as pssible. Refer t this Observatinal Reprt when drafting yur Final Shadwing Reprt. In yur Observatinal Reprt, remember t identify pprtunities fr imprvement, and prpse pssible slutins expressed by the patient, family, and Care Givers. And dn t frget t share yur wn imprvement ideas, t! A sample Observatinal Reprt fllws. Same Day Surgery Care Experience June 9, :00 AM Hspital and Same Say Surgery entrances Patient and wife arrive at hspital Truble finding the unit Discrepancy in signage (Outpatient Surgery vs. Ambulatry Surgery) Observed multiple patients arriving at Entrance A - n staff sitting at registratin desk at Entrance A patients and families nt sure where t g; N sign at desk directing patients t Surgical Waiting Rm Upn arrival at Waiting Rm, patients are tld t Sign In, Take a Seat -- n Hell, Gd Mrning, etc. After 5 minutes the patient was called back t the desk where patient demgraphics/id were reviewed and ID band was placed n patient, VERY quick review f Case Tracking, Parking Ticket validated at this time. Family members are tld nt t leave area withut letting the desk knw Intrduce self t patient and wife 5:17 AM Pre-Op Area Patient is taken back t get dressed Wife mentins husband s cmment f funeral music ver the speaker when entered the hspital

2 Patient is unsure hw lng the prcedure wuld last (20 minutes r a 4- hur surgery?) Patient had been infrmed f the tracking numbers Rm had tw televisins Half f each screen displayed the news & tracking mnitr n ther half TVs n ppsite sides (culd see frm any seat) Wife mentins parking is mre expensive than it used t be ($4) Her ticket was validated Wife is nt sure abut hme care after the prcedure Cmments made by Wife: Sheets in rms shuld be changed every day Phne and TV charges need t be explained better 5:45 AM Patient and wife intrduced t Pre-Op Nurse 6:00 AM Nurses intrduced themselves again and tk patient s vital signs, reviewed H&P, nursing assessment, cnfirmed prcedure (time with patient 10 min). 6:10 AM - 6:15 AM Anesthesilgist in t perfrm anesthesia assessment; RN s left the rm I bserved the lack f privacy cnversatin f patient s medical histry can be heard by thers utside f cubicle 6:15 AM 6:25 AM Nurses with patient t d Sage wipe and hair remval

3 6:24 AM Wife is tld she can g back t pre-p t see her husband Wman at frnt desk asks wife fr a cell phne number s that during her wait, she can be cntacted if she wuld like t leave the hspital Wife des nt knw her wn cell number Pre-p area is much cler than waiting rm (nted by wife) Curtains are pen; patients are able t view each ther 6:39 AM PA and 2 nurses enter patient area PA takes histry and perfrms physical exam Nurses speak t wife abut her husband s mediatins (cnfirmatin) 6:43 AM Anesthesia team member enters (SRNA) (thers caregivers leave the area) Asks pre-p questins and then asks if patient has any questins Wife is NOT addressed Inserts IV drip 6:48 AM OR RN enters, intrduces herself and her rle n the care team Asks patient abut medical histry (cnfirmatin) 6:49 AM Surgen enters the area & explains prcess (patient is happy t see him) 6:51 AM Surgen exits 6:52 AM

4 OR RN exits 6:58 AM 6:59 AM 7:04 AM OR RN cmes back t see wife t let her knw that she will be cntacting her with updates thrughut the surgery. CRNA s and anther nurse enter the area clse curtain Give heparin sht Tell patient that they are ready fr him Wife is able t stay in the area 7:06 AM Curtain pens Nurse explains t patient what he shuld expect Wheels patient t OR Nurse at nurse statin wishes patient gd luck and addresses him by name Anther nurse wishes luck t Wife Wife became tearful Nurse ffered supprt Wife kisses husband gdbye, but is NOT escrted back t the waiting rm; verbal instructins nly t g t waiting rm. Wife cnfused n where t g 7:09 AM Waiting Area Arrive in waiting rm 7:18 AM Smene walked arund ffering cpies f the lcal paper t patients (nice gesture!) 8:40 AM Becming luder and mre crwded in waiting rm

5 One family enters with six children wh must wait by themselves while their mther went t pre-p t see the patient Wife jkes where is the Krispy Kreme? (It wuld g well with the cffee!) Wife likes the vlunteers and thinks they are very helpful We jke abut hw nice a barista cart wuld be Wife talks n the phne t family at times during her wait 10:08 AM Wife is infrmed that there is a call frm the OR nurse with an update Tld abut surgery prgress and infrmed she wuld be given anther update 10:27 AM The mther-in-law f the patient s daughter cmes t the waiting rm t keep Wife cmpany She is immediately apprached by staff member and asked if she needs her parking validated Cpyright Anthny M. DiGiia III, MD, AMD3 Cnsulting, Inc. and The PFCC Innvatin Center f UPMC. All rights reserved.