Improve documentation with this plan of care
Form takes multidisciplinary approach to patients
Do you have some note-takers on your staff who leave much to be desired in their documentation? You're not alone. Most same-day surgery programs report inconsistency in their staff's level of documentation. Now there's help from Via Christi Regional Medical Center in Wichita, KS, which uses a comprehensive plan of care form to document patient care from pre-op to post-discharge, except for the intraoperative phase. The medical center uses a flow sheet for physical assessments. (Copies of the form and flow sheet are inserted in this issue.)
In addition to outpatient surgery patients, who are called partial day surgery (PDS) patients, the two forms are used for AM admits.
"For the poor documenters, it made a world of difference," says Rebecca Coffey, RN, project specialist at Via Christi.
The form also got the attention of the Joint Commission on Accreditation of Healthcare Organizations, Coffey says. "We found we did a much better job of meeting documentation requirements," including documentation of the nutritional evaluation and consult, spiritual needs, and education needs, she says.
Also, the form helped show continuity of care throughout the patient's length of stay better than a narrative documentation, she maintains.
The form is so simple and straightforward, patients probably could fill it out themselves; however, the RN does it for them, says Neal McKinney, BSNA, unit manager at Via Christi. "A lot of the time, patients are overwhelmed about coming in for surgery, and they don't think quickly. We walk them through [the form]," McKinney says.
Form is started before patient arrivesOn the plan of care form, the front page is a compilation of admission data. "When surgeries are scheduled ahead of time, this section is filled out prior to the patient getting to the hospital," Coffey says.
The pre-op checklist on page two also is filled out before surgery. "The dismissal checklist is there to remind nurses - these are the things that they need to take care of prior to the patient going home." Those items include some listed in Joint Commission accreditation guidelines, such as whether patients have been given prescriptions.
The post-hospital interview is generally done 48 hours after patients leave the facility. All patients who aren't reached on the first call are contacted a second time. "If we know the patient is going somewhere other than home, we try to document so we can call at the appropriate number," Coffey explains.
A clinical pathway begins on page three of the form and covers tests, treatment monitoring, prescriptions, activity, discharge planning, nutrition, education, and consults for patients in PDS, pre-op and post-op, pre-op holding area (POHA), surgery, and the post anesthesia care unit (PACU). Poten tial problems areas for patients are documented beginning on page five.
"In most areas, we only address whether the outcome was met or not," Coffey says. "Our purpose is to look at outcomes, because so many interventions related to these areas are standard protocol. We don't address interventions unless they're different than protocol. Then we document the variant" in the progress notes. Physicians maintain separate progress notes."
When an outcome hasn't been met or an intervention listed, the documenter puts a "U" in the box and writes a variance note. If the outcome is met, the staff person initials the form in that area. "In some areas, we have interventions listed, and you have to address each one," Coffey says. "It is up to the manager of that area what individual interventions need to be listed."
The eight most common problems for patients were designated by a multidisciplinary team that included representatives from nursing, physical therapy, occupational therapy, respiratory therapy, home health, case management, social work, and pastoral care. Having a varied group bringing together their ideas is reflected in the unique multidisciplinary nature of the form, Coffey says.
The potential problem areas are: comfort, skin integrity, communication, safety, mobility, and psychosocial, physiological, and spiritual issues. "If the problem is not appropriate for that patient - for example, if there's no communication barriers - it's handled with a slash through the box to designate that it's not appropriate," Coffey says.
Information is gathered from patients or their families. The form isn't just a nursing documentation tool, she emphasizes. Psychosocial issues may be documented by a social worker or pastoral care staff person, for instance. On the other hand, a nurse may document spiritual issues.
Coffey offers a word of warning about adding such a form to your program: "When we first started, people hated it. They thought it was time-consuming."
Staff have undergone an attitude turnaround, however. With a recent merger between Villa Christi and another Catholic facility, documents are being sorted to select one for both facilities. "People now want to stay with the form," she says. "It's very beneficial. It meets their needs, and it's simple to use."
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