Kardex divided into 4 sections 1 st section patient history: patient name, age, gestational age, gravity/parity, gestational age, due date, primary physician, home medications, allergies. History Exams Labs Procedure/Plan of care
2 nd section Exams: current findings vitals signs, vaginal exams, any bleeding, physical assessment. 3 rd section Labs: Patient’s current lab results: blood type, group beta strep status, RPR, HIV, HepBsag, Rubella, CBC,
History (Present Status) Exams (Pertinent Findings) LabsPlan of Care Mrs is a y.o. G……P……. Patient of Drs / □ GA EDD □ Elective □ Indicated □ Forceps □Vacuum— □ VBACx---- □ BTL yes----no □ Language Home medications □ PNV □ Iron □ Insulin □ BP □ Antibiotics □ Others T P R BP-----/----- Vag exam □ NKDA □ Allergies (item/reaction) / / Blood HbsAg Rubella HIV RPR GBS □ treated x Admission Labs □ T&S □ RPR □ CBC □ Walk in labs □ Rapid HIV Delivered □Vaginal □ C- section The at Meds Given in L&D □ Toradol 1 st dose time □ Ancef □ Motrin □ Tylenol □ Percocet □ Bebadryl □ Others Exams Able to void x Foley Episiotomy Laceration deg Dressing Dry and Intact Lochia WNL Diet Mother/Baby Plan of care Skin to Skin yes no Breastfeeding time----- Left breast: Right breast: Stool: yes no Void: yes no Baby □ Male □ Female Weight □ Twins (Time/Weight) A / M/F B / M/F □Breast □Bottle □ Circumcision □ HepB Vac □Vitamin K □ Erythromycin Prenatal Records □Yes □ No □SROM □ AROM □PROM Time: Complications □Yes □ No □GDM □ PIH □Anemia □PPH □PTL □Seizure □Meconium □Febrile □ Other RoomNameAge OBPed HELP Report/Postpartum Care Kardex
long term goals Enhance nurses autonomy while providing patients care Decrease patient safety risks due to errors, short terms goals Empower nurses on patients’ advocacy Provide effective patient care by reducing errors related to miscommunication
After the implementation of the tool, nurses on the unit will be able to: Identified the importance of effective communication during shift report Describe the importance of quality exchange information when handing over patient care Cite the benefits of using the new communication tool during shift report.
Monthly staff meeting 1. Survey questionnaire: rate the effectiveness of the tool from 1 to How helpful is the 3. tool related to your work? Please rate the quality of the tool.
Chapman, K. (2009). Improving Communication Among Nurses, and Physicians. AJN retrieved April 29 th, 2013 from Curtis, K., Tzannes, A., & Rudge, T. (2011). How to talk to doctors - a guide for effective communication. International Nursing Review, 58(1), Evans, D., Grunawait, J., McClish, D., Wood, W., & Friese, C. R. (2012). Bedside Shift-to-Shift Nursing Report: Implementation and Outcomes. MEDSURG Nursing, 21(5),
Christian, K., Haight, T. (2009). Improving communication using a cancer treatment schedule tool. Oncology Nursing Forum, 36(3), 15. Jefferies, D.(2012). Communicate with clarity. Nursing Standard, 26(40), Middaugh, D. J. (2013). Signal-to-Noise Ratio: Filtering Out Ineffective Communication. Medsurg Nursing, 22(4),
Institute of Medicine (2009) To Err Is Human: Building a Safer Health System, retrieved 10/30/13 from The Joint Commission (2007) Sentinel Event statistic retrieved 10/30/13 from rmation_1995-2Q2013.pdf