Assessment form follows patients in continuum
Repetitive questions eliminated
Faced with patient complaints about having to answer the same questions throughout the continuum of care, Sharon (PA) Regional Health Services has developed a health assessment form that is used by all parts of the health system from the emergency room to home health services.
The 41¼2-page Adult Health Assessment Form combines assessment forms from acute care, nursing, physical therapy, occupational therapy, speech, rehab nursing, recreational therapy, home health, outpatient services, and behavioral health.
Each area of the health system still uses specific assessment forms, but those have been edited to eliminate any questions contained in the general assessment form.
A separate committee of representatives from the various rehabilitation disciplines also created a multidisciplinary discharge summary form. (For details, see article, p. 114.)
Located between Erie and Pittsburgh, the health system includes an acute care facility, skilled nursing care units, rehabilitation, outpatient services, and home health. There are 19 inpatient rehab beds.
"We were constantly getting patient complaints that everyone was asking the same questions. We were doing repeat evaluations without sharing the information," says Barbara Cogley, RN, CCRN, NHA, coordinator of rehab services.
The idea for the new assessment form evolved during a systemwide redesign project. One team, charged with alleviating communication problems, identified the multiple assessment forms as a problem area.
"At the time, everybody did a separate form that asked the same questions Where do you live? Have you had heart problems? Are you allergic to any medications? And when the patient left acute care and went to rehab, his record stayed there and we started over with the same questions," Cogley says.
Under the old system, the patient might be asked the same questions three times during a short period of time: in the emergency room, in the acute care hospital, and in rehab.
Now the original form stays with the chart, and a copy moves through the continuum with the patient.
"The rehab staff has been really pleased with the new assessment. We were the ones who usually got the patients after they had gone through the emergency room and acute care and had been asked the same questions a number of times," Cogley says.
Having a standardized form that progresses with patients also benefits the rehab staff when patients are disoriented or aphasic, she says.
"By the time a trauma patient is admitted to rehab, the family isn’t always readily available. This way, someone else has gotten the information we need during the early stages of hospitalization when the family is more accessible."
The project was developed by a team of nine representatives from all areas of the continuum and all levels of staff, including professionals, aides, and secretaries. Team members took the committee’s work to their individual departments for review.
The team began by gathering assessments from all areas of the continuum, examining them on an overhead projector, and searching for duplication. They came up with a set of questions being asked several times during a patient’s stay and created one form including all commonly asked questions.
The team started meeting in October 1996 and started using the forms in early July 1997.
The new form includes past medical history; patient and family background; allergies; medication usage; community services being used; vital signs; and discharge planning needs, such as family and home situation. It also includes general questions about diet; bowel/bladder, psychological, and cardiac/respiratory function; anesthesia; activities of daily living; language spoken; contact people; spiritual and cultural needs; and glasses, hearing aides, and dentures.
If patients are confused, aphasic, or if there is any doubt about their ability to answer clearly, staff leave that section of the form blank until the families can be contacted. When patients are admitted to the next level of care, staff review the form and double-check any questionable areas.
All departments and disciplines were asked to adjust their evaluation forms to remove everything that was included in the continuumwide form. The physical therapy department, for instance, deleted questions on activities of daily living, past history, and home situation from its form and now concentrates only on questions relating to the physical assessment, Cogley says.
The staff responded well to the edict to combine the assessment forms, Cogley reports.
"It worked out better than we thought. Some people were territorial initially, but they are so busy with so much paperwork that they were willing to anything to cut down on paperwork."
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