Presentation on theme: "ASSESSMENT OF “CURRENT” PLAN OF CARE DOCUMENTION"— Presentation transcript:
1 If documentation is a reflection of our care, does it show that nurses make a difference?
2 ASSESSMENT OF “CURRENT” PLAN OF CARE DOCUMENTION Nurses reviewing other nurse’s documentation during the handover process find it hard to identify care priorities to focus onPaper Pathways are not easy to find in the pt’s chart, not part of the electronic record & nurses feel that printing is just busy workManagers & Regulators reviewing nursing documentation find it difficult to determine the most important patient problems – Recent JCAHO survey prompted us to try changes
3 A PILOT….8VCH and 8S VUH8 VCH & 8S VUH piloted a new way to document in HED…. “Priority Problems”Nurses like it because it’s easier to plan & manage patient care. Terminology is standardized and simplified using CCC Saba model.Nurses find that documenting “Priority Problems” is a PRACTICE change with no new computer skills to learn
4 OBJECTIVES….Verbalize understanding of the vision for Priority Problems and Clinical Care Classification* (CCC) Nursing terminology.Use CCC Nursing terminology to document planning and managing care for a practice scenario. IncludingAssign & save a pathway to a patient’s medical record in StarPanelInitiating 2-3 top priority problems and their expected and actual outcomesDocumenting shift expected/actual goals, Nursing Summary and PlansFor your area, initiate list of top 10 pathways and 5 problems for each. Define for common problems the problem category, problem, related to…., expected outcomes and short term goals
5 Vision StatementPriority problems will simplify and standardize how nurses:document and communicate the patient’s top priority problemsidentify plans and goalsassess actual outcomesThis will improve patient care and clearly define nursing’s contributions to patient care and the team.
6 What’s Changing Save Electronic copy of Pathway in StarPanel Identify 2-3 priority patient problems and outcomes and short term expected/actual goals using CCC modelWHY? Nurses, and all team members, need to focus on the most urgent needs & identifying the interventions to help patients achieve their goals.Not Changing:Document the pathway name, phase, nursing summary & plan priority in HED
7 Priority ProblemsWe all have different ways of describing or talking about problems. You call it pain, I call it alteration in comfortThe decision was made to standardize how we talk about nursing care. The Clinical Care Classification* (CCC) Saba Model was selected.
8 CCC Model is Evidence Based Over 40,000 charts were reviewed to derive the 182 Clinical Care Classification problems.The Clinical Care Classification (CCC) System* is a standardized, coded nursing terminology that identifies the specific elements of nursing practice.CCC provides a unique framework and coding structure for capturing the essence of patient care in all health care settings*Developed by Virginia K. Saba, RN , PhD
9 You can learn more on the Sabacare.com website about the CCC.
10 CCC Framework 21 Categories w/82 Problems 3 Expected Outcomes ImproveStabilizeSupport decline3 Actual OutcomesImprovedStabilizedDecline supportedRefer to glossary
12 3 CCC Outcomes For Priority Problems Expected/Actual 1. Improve/ImprovedCondition will change and/or recover (fracture, pneumonia)2. Stabilize/StabilizedUnderlying chronic condition will not change but requires no further nursing care to maintain (asthma, heart failure)3. Support Decline/Decline SupportedCondition will change and worsen (cancer, ESRD). Nursing action supports decline.
13 Putting it all together to Build an Outcome Oriented Documentation Framework
14 Priority Problems: What to Do & When AdmissionSelect & Save Pathway (StarPanel )Document Pathway Name & Phase (HED)Create 2-3 Priority Problems (HED)Beginning of ShiftReview Pathway & Phase - change prn (HED)Document expected Short Term Goals for your shift (HED)End of ShiftStart/End Priority Problems - adjust Pathway & Phase prn (HED)Document Short Term Goal Status or outcome (HED)Document Nursing Summary & Plan & Priorities for next shift (HED)Transfer/DischargeStart/End Priority Problems. Change Pathway &/or Phase prn.Document Short Term Goal & status (HED)Document Nursing Summary & Plan & Priorities in HEDDocument D/C Plan in HED & denote Post Discharge Plans to address unmet goals
15 Select & Save Pathway (StarPanel ) Document Pathway Name & Phase (HED)Create 2-3 Priority Problems (HED)AdmissionDay of go-live alsoChoose the pathway that most closely reflects the expectedpatient progression. Usually the reason for admission.EXAMPLES:Medical Pathway – Heart FailureAdmission – Orders & interventions are aimed at achieving stabilization (improving pump action through diuresis, O2, hemodynamic stability, . . .)Stabilization - achieving controlled symptoms (fluid excess control, med mgmt)Discharge – Ready for self-care; or care by another caregiver.Surgical Pathway - Knee ReplacementPre-opPost-op StabilizationDischarge
16 USE OF GENERIC PATHWAYS MAKE IT HARDER Specific pathways will have phases, goals and interventions that are a better fit.The evidenced based pathways can better guide care.Use generic pathways only as a last resort
17 List of pathways display Select & Save Pathway (StarBrowser/StarPanel )Document Pathway Name & Phase (HED)Create 2-3 Priority Problems (HED)AdmissionClick ActionClick EDOCS PathwayList of pathways display
18 3. Type the name of the pathway in search. 4. Click on Pathway to add to medical record5. Click OK to add to Starpanel
19 Click to display pathway Pathway Will Display in Assessment Section of the OPC with a Link for Easy AccessClick to display pathway
20 PRACTICE SCENARIO Admission: You are working day shift and your 27 yo ,Mary Lou was admitted to the Ortho unit around 5pm after an MRI revealed a cervical cord mass. She is experiencing weakness, is ataxic and has neck and back pain. Her pain score is a 5 with morphine on board. She is scheduled for a cervical laminectomy tomorrow. She is a single mother and concerned about her 4 and 2 year old children and how she will care for them after surgery.Assign best fit Pathway in StarPanelDocument Pathway and Phase in HEDCreate 2-3 Priority Problems (HED)Notice that the cervical surgery pathway does not have a preop phase so pick the best fit – Day of Surgery since the pt is going for surgery tomorrow.
21 Select & Save Pathway (StarPanel ) Document Pathway Name & Phase (HED) Create 2-3 Priority Problems (HED)Admission
22 Definitions located in “links” from HED Select & Save Pathway (StarPanel )Document Pathway Name & Phase (HED)Create 2-3 Priority Problems (HED)AdmissionBefore doing anything in HED, think about the 2 or 3 Priority Problems for Mary Lou. Review the CCC definitions as needed.Definitions located in “links” from HEDPlace a check mark next to them on “Standard Nursing Problem List”
23 Note the 21 categories of problems Document Priority Problems in Plan of Care TabNote the 21 categories of problemsLocate the 3 categories you identified for Mary Lou.
24 Click Start Priority problem AdmissionSelect & Save Pathway (StarPanel )Document Pathway Name & Phase (HED)Create 2-3 Priority Problems (HED)Click Start Priority problemSelect problemDenote “ may be related to…”Select expected outcomeType “T” for today's date and time or type in another date/ timeSave
25 Initiating a Problem Hover over icon to see detail of problem. Problem Screen works like IV Manage, Foley Catheter & Wounds.
26 Enter a Nursing Summary and Plan Priorities for the next shift since it is almost shift change time. Sample Nursing SummaryMother of 2 young children admitted w/ surgical mass scheduled for cervical laminectomy in am. Has weakness, ataxia and 5/10 pain.Sample Plan PrioritiesControl pain, prep for surgery & explain post op course, assure no falls and provide emotional support
27 Day and Night shift goals may differ. Review Pathway & Phase - change prn (HED)Document expected Short Term Goals for your shift (HED)Beginning of ShiftIn HED, type the short term goal for the shift for each problem that will be addressed that shift.Keep in Mind….Day and Night shift goals may differ.
28 Start/End Priority Problems - adjust Pathway & Phase prn (HED) Document Short Term Goal Status or outcome (HED)Document Nursing Summary & Plan & Priorities for next shift (HED)End of ShiftEnding problems works the same as ending a PIV or Foley. Select the magnifying glass, fill in appropriate fields.
29 Hover over icon to see detail of goal. Start/End Priority Problems - adjust Pathway & Phase prn (HED)Document Short Term Goal Status or outcome (HED)Document Nursing Summary & Plan & Priorities for next shift (HED)End of ShiftShort Term Goal StatusHover over icon to see detail of goal.Document status (met, improving, unchanged, deteriorating, not met.
30 Start/End Priority Problems - adjust Pathway & Phase prn (HED) Document Short Term Goal Status or outcome (HED)Document Nursing Summary & Plan & Priorities for next shift (HED)End of ShiftRule of thumb between the hours of 3 -5 to allow for printing of OPC for next shift
31 Start/End Priority Problems. Change Pathway &/or Phase prn. Document Short Term Goal & status (HED)Document Nursing Summary & Plan & Priorities in HEDDocument D/C Plan in HED & denote Post Discharge Plans to address unmet goalsTransfer/Discharge
32 Problems, expected outcomes and the short term goals and status. Reports will be ed to leadership every day to assist with monitoring progress of staff and patients.Problems, expected outcomes and the short term goals and status.
33 Common QuestionsPatients have many problems, what makes it a priority problem?When it is the patient’s priority (pain, SOB, anxiety)Keeps the patient from moving to the next phase (fluid volume excess)High probability for harm (infection risk, falls)Delays dischargeNote that Day & Night shift may have different priorities (ambulation vs. sleep)
34 Common Questions How do I choose the right problem descriptor? Example : My pt has Heart Failure – which problem do I pick?Match problem closely with the interventionsIf you are focusing on fluid mgmt (IV diuretics, I&O, low Na diet, fluid restriction) pick Fluid Volume ExcessIf you are focusing on breathing treatments, choose Respiratory AlterationNeither are wrong – both may be selected
35 What to doWhat NOT to doDo NOT Repeat all the problems from the pathway.Do NOT replicate standards of care unless they are specific to a priority problemDo NOT include “Continue to Monitor” unless there are details re: what to monitor.Do NOT change problems for a slightly better descriptor.Not all problems need be addressed every shift – day and night shift will have different priorities.Keep Problem List Short & UseableDo make Plan Priorities reflect priorities for the next 12 hr shift.Use problems started on prior shift until significant progress is made or the problem has been resolved.Make goals/ plans specific and realistic. Example monitor o2 sat w/ ambulationReview pathway and document any changes to pathway or phase.
36 Making Priority Problems Your Own Print 1 high use pathway for your areasUse the Priority Problem Assessment tool to identify 5 common problems for this pathway.3. Complete the Sample plan of care exercise for these 5 problems.4. Identify a plan to complete other 9 pathways sample plan of care or your area.
37 Training and Implementation Plan Live Date: TuesTraining Plan:90% of Staff Trained by go liveSmall groups will have opportunity to practice and ask questionsEveryone needs to practice before go live3-4 terminals will need to be identified to setup with priority problems in HED train… get those terminal IDs to your SSS person ASAP.Add to the practice scenario, a scenario for your patient population.
38 Training and Implementation Plan Resources:Priority Problem Resource ManualTop 10 pathways for unitExample of 5 common problemsSuper Users/ EducatorNeed enough super users for each shiftImplementation SupportSuper User 9a-5p and 9p-5a Tue- FridaySSS 9a-5p and for 2 hours between 9p-5a Tue- Friday
39 TO DO LIST ASK QUESTIONS Complete 10 Top use Pathway and 5 common problems exercise (suggested to involve super users)Complete Sample Plan of Care exercisesComplete Training Plan ( including recruiting super users)Identify 3-4 terminals to set up for practice and get terminal IDs to your SSS repASK QUESTIONS