2. SpeakerSpeaker
Lisa Rabideau, RN, BS, CPAN
Clinical Informatics Manager
CVPH Medical Center
Lisa Rabideau has completed commercial bias disclosure forms and do not
have any conflicts of interest.
3. Objectives
Define Care Planning
Contrast current care planning
process to future requirements
Demonstrate use of SNOMED-
CT terminology
Describe the future of
Interdisciplinary Care Planning
4. It is the policy of Corexcel and IMNE to ensure fair balance,
independence, objectivity, and scientific rigor in all programming.
In compliance with the American Nurses Credentialing Center
(ANCC) and the Accreditation Council for Pharmacy Education
(ACPE), it is the policy of Corexcel and IMNE that faculty disclose
all financial relationships with commercial interests over the past
12 months.
Corexcel’s provider status through the ANCC and IMNE’s provider
status through the ACPE, are limited to educational activities.
Corexcel, IMNE, ANCC and ACPE do not endorse commercial
products.
5.
6.
7. Open on current site 1926
Total licensed beds: 409
313 Acute Care beds
34 Psychiatric/Mental Health beds
96 Skilled Nursing Beds
42 temporary
>2300 employees,
521 RNs, 32 ISS staff, 163 physicians
Beautiful Midtown Plattsburgh, NY
CVPH Medical Center
11. Need to Strike a Balance
Data elements for reporting
Notes to tell the patient story
12. Nursing Care Plans
Intended to be plan to provide
care
Paper or Computerized
NANDA, NIC, NOC, CCC, PNDS
Done because you have to
Standardized - Individualized
13. According to the “Book”
Read the nurse’s admission assessment/history and
the medication record
Review the history, current diagnostic test results,
nurse’s notes for the last 48 hours, progress notes of
providers and current consultation reports
Interview the patient and complete an assessment
Read about the diagnosis
Select the appropriate standardized care plan
Select the nursing and collaborative diagnoses that
are appropriate
Modify the desired outcomes so they are
measureable and realistic
Select the nursing actions that are relevant
Ulrich, S. Canale, S. (2005) Nursing Care Planning Guides. Elsevier Saunders:
St. Louis, MO.
14. What really happens:
Assessment generates standard
problem
Nurse reviews problems and chooses
plans
Plans are pre-set with nursing orders
Generally not customized
At pre-determined interval, nurse
clicks “mark reviewed” on plan of
care page
Generates a clinical note with no
relevant content.
16. Influencing the Transition…
Meaningful Use Stage 1
The number of patients … who have at least one
entry (or an indication that no problems are
known for the patient) recorded as structured
data in their problem list.
ICD-9 or SNOMED-CT
Threshold 80%
MU Stage 2
Part of Transitions of Care
SNOMED-CT required
Threshold 65% of Transitions of Care
electronically transmitted
17. Moving from Nursing Care
Plans to Interdisciplinary
Problem List/Plan of Care
Currently used by Nursing
Consult orders go to other
services
Documenting done primarily in
assessments, some on paper
18. Initial Step
Took list of existing Nursing
Care Plan Problems
Found appropriate SNOMED
problem
Re-mapped and re-named
problems
19. Example of Crosswalk
Current Problems in
Test
Current Problems in
Prod
SNOMED options
Knowledge deficit of
community resources
Special educational needs
Knowledge deficit of discharge
planning
Knowledge deficit of discharge
planning
Special educational needs
Knowledge deficit of smoking
habit
Knowledge deficit of Smoking
habit
Smoker
Knowledge deficit of
therapeutic regimen-diabetes
mellitus
Knowledge deficit of
therapeutic regimen-diabetes
mellitus
Special educational needs
Skin integrity impairment Skin integrity impairment Broken skin, tear of skin,
pressure sore of (site), decubitus
ulcer
Skin integrity impairment risk Skin integrity impairment risk
Infection Infection Infection, Infection due to
resistant organism
Infection risk Infection risk Immunodeficiency disorder,
nutritional deficiency,
neutropenia etc
20. Problem Name Mapping
Problem SNOMED
Nutrition Deficit Risk Nutrition Impairment
Injury Risk Fall Risk
Fluid Volume Impairment Edema
Acute Pain Acute Pain
Infection Problem-Potential At Risk for Infection
Knowledge Deficit-Smoking Smoker-Current Smoker
Anxiety Anxiety
Skin Integrity Impairment Risk Risk for Impairment
Impairment Skin Integrity Actual Chronic Ulcer of the Skin
Activity Intolerance Risk Mobility Impairment
Breathing Pattern Impairment Respiratory Distress
Body Weight Impairment-Bariatric Obesity
Sleep Pattern Impairment Disturbance in Sleep Behavior
Knowledge Deficit
Therapeutic Regimen- Diabetes
Diabetes Mellitus
Chest Pain Acute Chest Pain
Comfort Care Dying Process
21. Problems not in
“Starter Set”
Entrapment Precautions
Elopement Precautions
Comfort Care, Dying Process
(added manually)
Restraints
22. Care Plan Orders
Met with sub-group of Nursing
Documentation Team
Edited care plan orders to
minimize duplication,
redundancy
Reviewed existing plans 1 by 1
23. CPOE Order Sets
Contain Nursing Orders for
appropriate problems.
Use of Nursing “Protocols”
Drive “Problem Order” to Plan of
Care
24.
25. Protocol Content
A. Assessment:
1. Assess the location, radiation and duration of pain.
2. Assess intensity of pain on scale of 0-10.
3. Assess quality of pain (pressure, throb, heavy, burn, ache, sharp).
4. Identify events leading to episode of pain.
5. Assess EKG & telemetry strips for irregularities and ST changes.
6. Monitor blood pressure, apical pulse.
7. Monitor respiratory rate, character, and oxygen saturation.
8. Monitor skin color and temperature, presence of diaphoresis.
9. Monitor LOC (level of consciousness).
B. Interventions:
1. Provide oxygen to the patient during chest pain episodes and next 24
hours. Re-evaluate according to oxygen protocol.
2. Assess the need for nitrates, antacids, and analgesics.
3. Call for a STAT EKG to be done according to criteria outlined in General
Information.
4. Implement patients coping strategies in reducing pain.
5. Assess blood pressure after EKG if no relief of pain.
6. Administer nitroglycerin per orders.
7. Provide a calm environment.
a. Turn lights to dim.
b. Utilize patient support systems in reducing anxiety as appropriate.
c.Turn off television or any other excess noises.
29. Standards of Care
Use Marker Model of structure,
process and outcome standards
Address nursing process (APIE),
Basic needs (activity, nutrition,
elimination, sleep, comfort),
Safety and Health management
(including education)
30. Move to Interdisciplinary
Plan of Care
Using plan of care display for
multidisciplinary rounds
Start with Respiratory and Discharge
Planning
Document clinical note from Care
Plan under pertinent section of care
plan problem.
Clinicians have clearer “patient story”
31.
32.
33. EDIS & Provider
Documentation
Problem list now populated with
both nursing and medical
problems
Sometimes the same
Learning curve for nursing and
providers
42. Resources
AHIMA Workgroup. "Problem List Guidance in the EHR."
Journal of AHIMA 82, no.9 (September 2011): 52-58.
CVPH Medical Center Community Service Plan September
2012
Dykes, P., DaDamio, R., Goldsmith, D., Kim, H., Saba, V.
Leveraging Standards to Support Patient-Centric
Interdisciplinary Plans of Care. AMIA Annual Symposium
Proceedings 2011; 2011: 356–363.
Matney, S., Warren, J., Evans, J., Kim, T., Coenen, A., Auld, V.
Development of the nursing problem list subset of SNOMED-
CT. Journal of Biomedical Informatics.
doi:10.1016/j.jbi.2011.12.003
Patient Services Standards of Care (2013), CVPH Medical
Center, Plattsburgh, NY
Ulrich, S. Canale, S. (2005) Nursing Care Planning Guides.
Elsevier Saunders: St. Louis, MO.
43. Soarian Clinical Solutions Track 2
Session # 11
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Notes de l'éditeur
Beginning of multi phased documentation reduction plan to get nurses out of the computer and focused on the patient while documenting essential information in a usable way. Systematized Nomenclature of Medicine - Clinical Terms Explain the path we are on toward Interdisciplinary documentation and planning care
Located in far northern NY near the Canadian border. Just across Lake Champlain from Burlington VT. Lake Champlain was the 6 th Great Lake for about a day.
First Building open in 1926 Physician’s Hospital, Merged with Champlain Valley hospital, run by the grey nuns, (opened in 1910), in 1967 CV hospital closed in 1972 and pts transferred to new addition, renamed Champlain Valley Physicians Hospital, CVPH. Plattsburgh State University purchased CV building
This licencing info is from 2012, but 2013 brought some changes to skilled nursing beds,
Documentation like many other things has been on a pendulum. Many years ago documentation was all narrative Subjective, objective, assessment plan Assessment , plan, intervention, Evaluation Problem (by number) Intervention, evaluation Focus on positive, progress toward goal Graphs of vital signs, I & O, meds Swung toward structured data that can be reported and easy to chart, but don’t show the whole picture. 3 pts with same checks totally different clinically.
NANDA- North American Nursing Diagnosis Association NIC- Nursing Intervention Classification NOC- Nursing Outcome Classification CCC- Clinical Care Classification , VIrginia Saba, care componenets PNDS- Perioperative Nursing Data Set What is a nursing diagnosis? A nursing diagnosis is a clinical judgment about actual or potential individual, family, or community experiences/responses to health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability. A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human response to actual or potential health problems and life processes. For example, a medical diagnosis of Cerebrovascular Attack (CVA or Stroke) provides information about the patient’s pathology. The complementary nursing diagnoses of Impaired verbal communication, risk for falls, interrupted family processes and powerlessness provide a more holistic understanding of the impact of that stroke on this particular patient and his family – they also direct nursing interventions to obtain patient-specific outcomes.
Multiple entries of “Care Plan Reviewed” with no other information in the note. Frustrating and useless to the Provider and other clinicians.
ICD- International Classification of Diseases, AMA used for billing. Move toward 10 which the rest of the world is using. Transitions of Care – Summary of care transmitted electronically. “ We proposed to describe transitions of care as the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.”
Done by myself and CMIO
Differences between test and prod environment in list of problems used for care plan.
There were a couple of current nursing problems that didn’t have a corresponding match in our starter set. Using Risk of elopement for cognitvely impaired subject (observable entity) [439166003] Dying process (observable entity) [399069006]
Nursing Documentation team working one 3 initiatives: Decrease admission and shift assessment length Improve care plan process Pertinent clinical notes
Duplication comes from many sources: Order sets, not discontinuing duplicate orders. Putting orders for things contained in a nursing protocol. Use the Marker Model of standards. Structure, process and outcome standards. 1988 Carolyn Smith-Marker Protocols are a process standard requiring nursing thought and judgement. Have embedded an “order” for the problem in order sets that is driven by workflow to the problem list.
Previous care plan order set for Chest pain.
Current orders decreased to orders for the appropriate protocols.
Those nursing measures not addressed in a protocol format are either part of the unit standard of care or are added to problem specific order sets.
Each unit/specialty defines standards for assessment, reassessment and the other needs. Critical care, perioperative services, Med-surg
Currently DP documenting notes in Softmed (3M) which we have pointers to in Soarian. Hisotorically not discoverable, no longer true. Move them to Soarian. Als plan to get Resp Therapists to put pertinent notes from plan of care problem. Accurate picture of patient condition requires a full “patient story” Rush University developing pt story display, similar to clinical summary to show things pertinent to pt on one screen- pt home page. Includes problems, diagnoses, nutrition, upcoming tests (itnerary), as well as nursing info on current lines, airway, drains, wounds issues.
Example of clinical note initiated from plan of care
Actual display of clinical notes from a patient.
In this case nursing documentation has generated problems for this patient based on past medical history of CAD and Cloitis and the presenting complaint of Abdominal pain
Search on Abdominal pain brings up pain choices, nurse could choose Acute pain plan to apply
The nurse can then go to create a plan of care, enter the problem and see what plans are available to use, or add nursing orders individually.
Pneumonia is the first problem being driven to the problem list from an order set. Next will be heart failure. Not using interventions except for post op vitals, will drive interventions from the plan of care for data elements that need reporting or things important not to forget. DKA order set driving 2 problems: Diabetes and DKA. The DKA may resolve but the pt will still be diabetic.