1 patient assessment, plan of care, and medical records kelly frank, rn, bsn health facilities...
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Patient Assessment, Plan of Care, and Medical Records
Kelly Frank, RN, BSNKelly Frank, RN, BSN
Health Facilities Surveyor Health Facilities Surveyor
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Objectives For This SessionObjectives For This Session
Describe the required components of patient assessment and patient plan of care in the new ESRD CfCs
Identify the expected timelines for completion of the patient assessment and patient plan of care
Describe the medical record documentation for the patient assessment and plan of care
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We Are Playing Different Positions On the Same Team… And the Goal Is…
Improving patients’
well-being through
improved outcomes!
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Change in Focus: Patient Assessment & Patient Plan of Care
From LTP/PCP to PA/POC Hard to talk about PA without talking about
POC NOT about paper! About collaboration of the interdisciplinary
team (IDT) About better outcomes for the patient:
“attain and sustain”
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Outcomes Based on ESRD Clinical Practice Standards
Developed by renal community workgroups & coalitions; e.g. National Kidney Foundation Kidney Disease
Outcomes Quality Initiative (NKF KDOQI) Guidelines
National Quality Forum (NQF): Clinical Performance Measures (CPM)
Address management of complications of ESRD
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Measures Assessment Tool (MAT)
The MAT is a tool developed for ease of reference to these Clinical Practice Standards
MAT was deliberately developed for ease in updating
If an individual patient does not meet a goal on the MAT, the plan FOR THAT ASPECT of care must be revised
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Patient Assessment & Patient Plan of Care
These 2 Conditions:Are interrelated (“can’t have one without
the other”)Address patient assessment & care
delivery requirements in “care areas” associated with complications of ESRD
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Patient Assessment and Plan of Care
Best Friends Forever
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The New Conditions Place High Expectations on Facilities for
Interdisciplinary approach for continually assessing individual patient’s care needs, and for planning and implementing the care.
Outcome goals that meet current professionally-accepted clinical practice standards
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Interdisciplinary Care vs. Multidisciplinary Care
Interdisciplinary Multidisciplinary
Work collaboratively Work sequentially
Communication by regular discussions about patient status & the evolving plan of care
Medical record is the chief means of communication
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Interdisciplinary Team
Collective vs. Individual
Problem Solving
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Interdisciplinary Team (cont.)
Includes at a minimum: The patient or his/her designee A registered nurse A physician treating the patient for ESRD A masters prepared social worker A registered dietitian
Required for both patient assessment and plan of care
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Patient Assessment § 494.80
The interdisciplinary team (IDT) must collaborate to provide each patient an individualized comprehensive assessment
14 assessment “criteria” Most required sections do not specify “who” must
conduct the assessment Reassessments required at defined frequencies
“Unstable” = monthly “Stable” = annually
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Patient Plan of Care § 494.90
The IDT must develop & implement a written, individualized comprehensive patient plan of care (POC) Based upon the comprehensive assessment Addresses each patient’s care needs
Outcome goals in accordance with clinical practice standards – MAT
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Stable / Unstable
Stable patients: annual comprehensive interdisciplinary reassessment POC updated & implemented within 15 days
Unstable patients: monthly comprehensive interdisciplinary reassessment POC updated & implemented within 15 days
All patients: continuous monitoring of any aspect of care where the target is not met & revision of that aspect of POC
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Who Is “Unstable?”
Includes but is not limited to: Extended (any stay >15 days) or frequent
hospitalization (>3 hospitalizations in a month)
Marked deterioration in health status Significant change in psychosocial needs Concurrent poor nutritional status,
unmanaged anemia & inadequate dialysis
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In Between Assessments…
Every patient must be continuously monitored.
If a “stable” patient’s outcomes do not meet the care plan goals in an area, the facility must recognize and address that aspect by revising the plan of care for that aspect between comprehensive reassessments.
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Correlation of PA & POCPA POC
1. Current health status (V502)2. Lab profile (V505) 3. Medication/immunization history
(V506)
Incorporated into all POC tags
4. Appropriateness of dialysis prescription (V503)
Adequate clearance (V544)
5. BP/fluid management needs (V504)
Manage volume status (V543)
6. Assess anemia (V507) Manage anemia (V547)Home pt ESA (V548)ESA response (V549)
7. Assess renal bone disease (V508)
Manage mineral metabolism (V546)
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Correlation of PA & POCPA POC
8. Nutritional status (V509) Effective nutritional status (V545)
9. Psychosocial needs (V510)10. Evaluate family support (V514)
Psychosocial counseling/referrals/ assessment tool (V552)
11. Access type/maintenance (V511)
VA monitor/referral (V550) Monitor/prevent failure (V551)
12. Evaluate for self/home care (V512)
Home dialysis plan (V553)
13. Transplantation referral (V513) Transplantation status: plan or why not (V554)
14. Evaluate current physical activity level & voc/physical rehab (V515)
Rehab status addressed (V555)
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For Each of the Care Areas IDT must assess each patient, develop &
implement POC to achieve established targets
Goals based on current clinical practice standards – MAT
If expected outcomes are not achieved, in any area, IDT must recognize and address this aspect
Must adjust the plan/implement the changes
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Current Health Status & Medication History
Assessment Medical & nursing histories & physical exams Must include etiology of kidney disease & listing
of co-morbid conditions Initial review of current medications & allergies Ongoing assessment of home medications
Plan of care for these aspects is addressed in Plan of care for these aspects is addressed in other care areasother care areas
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Immunization
Assessment: evaluate the patient for Immunization history/status for hepatitis ,
influenza, pneumococcal pneumonia HBV, tuberculosis screening
Must know HBV status on admission or tx as positive
Plan of Care: offer the patient Influenza & pneumococcal vaccines HBV vaccine for all susceptible patients
Retest vaccinated patients for response
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Blood Pressure & Fluid ManagementAssessment: Patient’s B/P on & off dialysis Interdialytic weight gains Target weight & intradialytic symptoms
Plan of Care: Achieve targets in fluid/weight management – MAT Symptomatic drops in BP or continued hypertension
during dialysis require plan revision
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Anemia Management
Assessment: evaluate the patient’s: Laboratory values for Hgb, Hct, serum ferritin,
transferrin saturation Associated co-morbid conditions Appropriateness for ESA &/or iron therapy
Plan of Care: provide care aimed at Achieving established targets in anemia
management – MAT Adjusting medications as indicated (may use
algorithms/ESA protocols)
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Nutritional Status
Assessment by dietitian: see list at V509 Albumin Body weight
Plan of Care: provide care & counseling aimed to:
Achieve & sustain effective nutritional status (V545) - MAT
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CKD Mineral Bone Disorder
Assessment: evaluate the patient’s: Laboratory values for calcium, phosphorus, iPTH Relevant dietary factors Need for medications: phosphate binders, vitamin D
analogs, calcimimetic agents
Plan of Care: provide care aimed to: Achieve established targets (calcium, phosphorus,
iPTH) in CKD-MBD management – MAT Adjust medications as indicated; may use
guidelines/algorithms Provide dietary education/counseling as indicated
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Dialysis Adequacy
Assessment: required for every patient: HD: initial & monthly Kt/V (or equivalent measure, URR) PD: initial & at least every 4 months Kt/V (or equivalent
measure, none currently)
Plan of Care: Prescribe treatment aimed at achieving HD spKt/V of at
least 1.2 (3 tx/week); PD Kt/V of 1.7; or Modify the dialysis prescription; or Provide a rationale for not achieving the expected target
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Dialysis Access: Assessment
Assessment for most appropriate access for that patient: AVF, AVG, CVC, PD catheter Consider co-morbid conditions/risk factors, patient
preference Evaluation for/of HD access:
Communicate with radiologist, interventionist, vascular surgeon
Do venous mapping, place new access as indicated Evaluation of PD access
Absence of infection: exit site/tunnel, peritonitis Patency & function
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Dialysis Access: Plan of Care
Patient evaluation as candidate for AVF If CVC >90 days, action plan for a more
permanent vascular access or rationale for continued use
Vascular access monitoring: To ensure capacity to achieve & sustain adequate
dialysis treatments For early detection of failure & Timely referrals for interventions
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Psychosocial, Functional Status & Modality Needs: Assessment
Evaluation by SW: see list at V510 Abilities, interests, preferences, goals for
participation in care, modality & setting Family & other support systems Physical activity level Referral for vocational & physical rehab Suitability for transplant referral based on
area transplant center criteria
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Psychosocial, Functional Status & Modality Needs: Plan of Care
Counseling and referral as indicatedAddress physical & mental functioning &
rehab needsHome care plan (or why not)
Transplantation referral (or why not)
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Timelines: All Began 10/14/08
Initial comprehensive interdisciplinary assessments for new patients:• PA = 30 days/13 treatments whichever is later• POC implemented within this same timeline
Comprehensive reassessment for new patients:• 3 months after initial assessment completed• POC updated & implemented within 15 days of
reassessment
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What About Current Patients on October 14, 2008?
Need a plan to implement this new system Complete some assessments/POCs each
month until all are done All current patients should be included in the
new system by 10/14/09 Three month reassessments for current
patients are NOT expected Any aspect of care that does not meet targets
must have an updated POC
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What’s Wrong With These Pictures?
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The ESRD Medical Record
Format - Electronic, manual, combination Content - Consents - Histories/medical exams - Progress notes - Labs - Treatment orders - Dialysis treatment records - Patient education
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Medical Record Documentation
Patient assessment Patient plan of care development/revision Plan of care implementation
May be found in multiple parts of the record
Use of the Mat
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Quality Patient Care Is About the Process…Not the Paper
Patient Assessment Plan of Care
