How to address assessment of patients
It's one of the most frequent concerns addressed to the Joint Commission of Accreditation on Healthcare Organizations: What do you do when your facility's forms committee says the same-day surgery area needs to use the same patient assessment form as the inpatient areas. You know that form: It goes on, and on, and on.
"Why? I don't know. We never asked you for that," says Ann Kobs, sentinel event specialist for the Department of Standards at the Oakbrook Terrace, IL-based Joint Commission. Kobs spoke at the recent Same-Day Surgery Conference in Palm Beach, FL.
"You capture the important information and move on from there," Kobs says. "You don't have to document it to death."
Patients' needs drive assessment
Standard PE.1 in the standards manuals says the extensive nature of the assessment will be determined by health needs of your patients. Since same-day surgery patients are in the facility briefly and are basically considered well patients, the assessment should be brief, concise, and limited to reasons the patients are presenting, Kobs says.
For example, if a patient is coming in for a cystoscopy, "you really don't need to know he or she had chicken pox at age 6," Kobs says. The test is whether the information is useful to the procedure your facility is performing on that day.
Even brief assessments should address physical, psychological, and social issues, however, she emphasizes.
Areas such as nutritional assessment may or not be pertinent, she says. Decide how you're going to address extended needs such as this one, Kobs advises.
Standard PE.1.6 says the timing of the initial assessment is conducted per hospital policy. "This is where we definitely would expect to see the H&P [history and physical] are on the chart before surgery," Kobs says. "That's a given. Not that it's dictated. That's not enough."
One of the biggest areas of concern regarding patient assessment is that the assessment is entered into the medical record within 24 hours, according to the Comprehensive Accreditation Manual for Hospitals [PE.1.6.1] - 8.4% of facilities surveyed from January to July 1997 received a type I recommendation in this area.
Facilities need to spell out in their policies and procedures that the H&P, along with tests and diagnoses, are on the chart before surgery and should spell out the time frame for doing so. The pre-anesthesia assessment and a second assessment, which is the last check before the anesthetic is administered, should be documented.
Patients should be given the risks, benefits, and alternatives regarding anesthesia, and they should be able to make a conscious decision about what they're choosing.
"There's assessment and reassessment at planned times," Kobs says. "When you do it is up to you."
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