Patient Tracer Summary

1 January 2017

In order to be compliant with Joint Commission standards for Record of care, Treatment and services an assessment was done which is outlined below. Introduction The admission assessment is the fundamental baseline assessment which begins the process of assessment, diagnosis, planning, intervention, and evaluation. This assessment is a critical first step in the patient’s care and serves as the first complete introduction the nurse has to the patient. During this process, the nurse assesses the patient from head to toe and establishes a baseline assessment.

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This provides a point of reference for other nurses to compare against to see if the patient’s condition is improving or declining. The history and physical also points out problem areas to the nurse, which allows him or her to write a care plan that will guide the nursing staff in their care of the patient. For example, a patient may be admitted for excessive uterine bleeding, but during the assessment the nurse notes that the patient has experienced significant weight loss and is at risk for skin breakdown because she has poor skin turgor, and is immobile and incontinent.

The nurse would write a care plan on the bleeding as it relates to, additionally, the nurse could write a care plan on the patient’s risk for skin breakdown and nursing interventions to reduce the patient’s risk for developing a decubitus ulcer. The nurse could also make a referral to the dietitian to help with the patient’s nutritional status. In response to this assessment an action plan was formulated to investigate the entire care-planning process: the initial assessment form, how it was used, what conclusion it rendered, and how the care plan was activated and reevaluated.

The nursing team involved the SDS nurse, OR nurse and PACU Nurse This initial involvement of the team not only brought the problem to the forefront of the nurse managers’ thinking, it also initiated the development of a solution. On reviewing the nursing process as it existed and as it applied to care plans it became very clear that care planning depends upon the nursing process and the nursing process is predicated upon the baseline nursing assessment. At this point, the problem was with the initial assessment process admission assessment process and care-plan development.

On examination of the existing assessment forms it was identified that nurse managers had utilized the existing form or some adaptation of the original for years. Although the staff was quite familiar with its format, it contained several identifiable flaws. ·It had been typeset and printed internally. ·New JCAHO standards or practice updates were often inserted wherever they could be worked into the form. ·The form did not provide a summary section for the nurse to consolidate his or her findings in preparation for the care plan, nor did it provide a summary section for other care members to review. Improper flow of assessment on the form. ·The form did not provide for a summary conclusion from which to develop a thorough care plan. ·The nurses didn’t necessarily like the form, but they had been using it for many years and no changes had been recommended by management. At this point one of the issues identified was that the nursing admission assessment form needed to be redesigned in order to be compliant and a proper flow patient care was documented for admission right up to referrals or discharges.

Corrective Action Plan: After identifying the problem a goal was set up to develop a new form that needed to be user friendly for the nursing staff, yet functional. The corrective action should include: ·Easy flow of information and reader friendly. ·Typesetting should be professional. ·It should include an overall summary section for team members to review. ·Accreditation requirements must be interwoven in natural flow within the context of the assessment and become more meaningful components to the assessment:

The design of the new form was based on the following research: ·This format would include prompts, interwoven accreditation requirements, and a summary section. ·Nursing topics were grouped together so that it flowed logically together and the nurse only needed to indicate negative exceptions to a healthy assessment. This would also minimize charting and clarify problematic areas in the patient’s assessment. If a section was normal, a quick check box indicating “no problems noted” was provided. The form also grouped together the need for financial assistance, need for case management referral, spiritual considerations, suspected abuse and neglect, and assistance at home, as well. Prompt boxes were also designed by these sections because it was the team’s belief that referrals to case management, the business office, and social services were also important in care planning. Such referrals or at least the documentation of the referral, had often times been missing on our old assessment form. Referrals for regulatory requirements to PT (physical therapy), OT or SLP, Nutritional counseling and spiritual considerations were looked at to identify their placement.

Once the form was ready, it was reviewed by Management which included the CEO, vice-president of nursing and legal council advisor. Implementation of corrective Action Plan: ·A training session was conduced within the nursing units to review and asses the form. ·The staff provided favorable feedback about the new assessment process, stating that they liked it and that it saved them time. The nurses in charge of audits stated that the form helps her when she’s looking for compliance With regulatory issues ·The Nurse working in admitting patients stated that it greatly simplified this assessment. Conclusion: The development and identification of this assessment form was a process resulting from research based on guidelines as per JHACO. The record of care, treatment and services clearly states that it should comprise of all data and information gathered about a patient from the moment he or she enters the hospital to the moment of discharge or transfer.

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