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Documentation & Communication

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Presentation on theme: "Documentation & Communication"— Presentation transcript:

1 Documentation & Communication

2 The Challenge: Research demonstrates that clear communication & documentation for mobility planning enhances function for our seniors during their stay in hospital Unclear communication & documentation leads to ineffective use of time trying to determine exactly what our patients are able to do in terms of how they move and how this changes on a daily basis for most

3 The Solution: Clear Documentation & Communication:
Baseline function: How did my patient move before admission? (pre-admit functional status) Record the following in the chart: Mobility level on a daily basis (assessment) Mobility activities (interventions) Frequency Duration Example: For a patient who can pivot to a chair: up to chair x2 for 30 minutes, ROM exercises done x3, dangle edge of bed 10 minutes.

4 Establishing a Mobility Care Plan:
Establish baseline functional status and plan accordingly Out of bed daily for all patients Aim to have patients mobilize at least 3x day Progressive mobilization that is optimized daily: Every day, do a little more… Ensure that mobility activities are recorded daily: “ If it’s not documented, it didn’t happen”

5 Communication: Key points for success
Integrate discussions about mobility into rounds Communicate how your patient is mobilizing at shift report Encourage clear medical orders that are action oriented (out of bed vs. AAT) Use patient/family boards to display mobility to engage patients and their families Use an inter-professional approach to creating & delivering mobility care plans

6 A Final Note: Where do I find Information about Mobility?
In the chart: Medical Doctor progress notes Occupational and physiotherapy notes Consult section of chart Nursing Notes Other places: Patient information boards Kardex Care pathways if applicable Communication boards for rounds

7 Acknowledgements <Your Hospital Name> is a member of the MOVE Collaboration, which is supported by the <insert funder’s name> The materials presented here are adapted from the MOVE iT initiative supported by the AFP Innovation Fund, Ontario Medical Association and Ministry of Health & Long- term Care


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