Doesformatmatter?ExploringtheuseofatemplatefordocumentationintheEMR

EstherAmmon,LCSW,ACHP-SW4thSWHPNAnnualAssembly2016

* Explorethevalueofutilizingatemplateforpalliativeandhospicesocialworkdocumentationintheelectronicmedicalrecord(EMR)* Reviewanexampleofapalliativepsychosocialassessmentandf/unotetemplate*  IdentifytoolsandstrategiesthatcanbeutilizedintheEMRtooptimizedocumentationofsocialworkcontributionsandsupportoutcomesmeasurement

Objectives

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* Structuralfactors* Notelength*  Informationdensity*  Informationalquality* Documentquality

PrinciplesofDocumentation

Whatdothedatashow?

* Shenetal(2012)* Nerietal(2014)

* Marilletal(1999)

* Roseetal(2001)

*  Template=documentquality

*  Template=documentqualityforspecialists*  Template=documentquality

*  Template=documentquality

UseofTemplate

Advantages/Benefits*  Increasedefficiency*  Increasedorganization*  Increasedcomprehensiveness*  Enhanceinterdisciplinary

communication*  Promoteuniformity

Disadvantages/Burdens*  Focuson“checklist”*  Focusonsequence*  Decreasedevaluationtime*  Increaseingrossbilling*  Poordesign*  Lesspatient/familycentered

*  DocumentationGuidelines*  NASW,NHPC,JointCommission,CMS

*  Settingspecific(?Institutionguidelines)*  UnitSW?*  Specificjobdescription/requirements*  SWAT,PIP

SWinPCandhospice

*  EmphasisonInterdisciplinaryteam(IDT)engagementandcollaborationwithpatientandfamilies*  Emphasisoncoordinatedassessmentandcontinuityofcare*  Clarityandspecificityofinterdisciplinaryteamcomposition*  Qualityassessmentprocess

Domain1:TheStructureandProcessesofCare

*  Standard6.EmpowermentandAdvocacy.

*  Standard7.Documentation.Socialworkersshalldocumentallpracticewithclientsineithertheclientrecordorinthemedicalchart.Thesemaybewrittenorelectronicrecords.

*  Standard8.InterdisciplinaryTeamwork.*  Standard9.CulturalCompetence.

AffirmationofNASWStandardsforPalliativeandEOLC

PALLIATIVECAREPSYCHOSOCIALASSESSMENTPreferredlanguage:LanguageUsed:SourcesofInformation:Barrierstoassessment:NoneNextofKin(NOK):***PrimaryCaregiver:OtherContacts:***　ChiefComplaint:Iamfeeling***HPI:Thisconsultationwasrequestedby***Supportsystem:()Strong()Fair()LimitedsupportsystemComments:Copingstatus-patient:Copingstatus-family:Physicalaspects:Learningneeds?()Language()Cultural()Developmental()Motivational()CognitiveComments:Religious/Spiritual/Existentialaspects:()Yes()NoComments:Assessment:PlanofCare:CoreMeasures:　 Yes No PalliativeCareEducation X 　 PastoralCare X　 　 TherapeuticCounseling X 　 AdvancedCarePlanning X　 　X AssessStress X 　 AssessCoping X 　 AssessAnxiety X 　 AssessAnticipatorygrief X 　 FamilyMeeting X　 　X Bio-ethicsconsult X　 　X PCSInterdisciplinaryRounds X 　X

* Contactinformation* Reasonforconsult*  Interventions* PsychosocialHistory* Advancedcareplanning* Assessment* Planofcare

Palliativepsychosocialassessmenttemplatecomponents

PALLIATIVECAREPSYCHOSOCIALASSESSMENTPreferredlanguage: LanguageUsed:SourcesofInformation:Barrierstoassessment:NextofKin(NOK):PrimaryCaregiver:OtherContacts:

TemplateExample

ChiefComplaint:Iamfeeling***HPI:Thisconsultationwasrequestedby***Supportsystem:()Strong()Fair()LimitedsupportsystemCopingstatus-patient:Copingstatus-family:Physicalaspects:Learningneeds?()Language()Cultural()Developmental()Motivational()CognitiveReligious/Spiritual/Existentialaspects:()Yes()NoAdvancedCarePlanning:Patientdoesnothaveanadvanceddirective.Goalsatthistime: ()Curative()Restorative()Longevity()TorelievedifficultsymptomsCodeStatus:FullPOLST(PractitionerOrdersforLifeSustainingTreatment):CandidateAssessment:PlanofCare:

CoreMeasures: Yes No

PalliativeCareEducation X

PastoralCare X

TherapeuticCounseling X

AdvancedCarePlanning X

AssessStress X

AssessAnxiety X

AssessCoping X

AssessAnticipatoryGrief X

ReikiSession X

FamilyMeeting X

Bio-ethicsconsult X

PCSRounds X

HPI:Thisconsultationwasrequestedby***.Ptisa***withPMHof***.Followingforpalliativepsychosocialassessmentandinterventioninsettingofseriousillnesstrajectory.Metwithptbedside.Introducedselfandsupportiverole.Ptabletoparticipatewithassessment.Amenablewithintervention.Pleasantandeasilyengaged.Ptreadilydiscussesillnessdescribing***Expressingfeelingsof****around***.Feelingsvalidated,normalized.Exploredwaysinwhichillnesshasimpactedlife,suchas***Confirms/deniesthatpain/symptomshaveimpactedcopingExploredhelpfulcopingstrategiessuchas***Reinforcedongoingavailabilityforpsychosocialsupportinsettingofseriousillnesstrajectory.

HPI&Intervention

Supportsystem:Copingstatus-patient:-Pleasantandeasilyengaged.-Describesnormativefeelingsofsadnessandlossarounddeclineinfunction.-Abletoselfsoothe.Abletolookforwardtothefuture.Copingstatus-family:ThemesofcumulativecaregiverfatiguePhysicalaspects:Reportshe/shewasindependentwithADL’spriortohospitalizationLearningneeds?()Language()Cultural()Developmental()Motivational()CognitiveReligious/Spiritual/Existentialaspects:()Yes()NoUtilizesfaithtocopewithstressofseriousillness.Importantspiritualresourcesinclude:***Whilehe/shehasnoformalreligiousaffiliation,he/shedoeshaveaspiritualphilosophythatguideshislife.Confirmsawarenessofpastoralcareasaresource.

PsychosocialHistory

Copingstatus-patient:Pleasantandeasilyengaged.Describesnormativefeelingsofsadnessandlossarounddeclineinfunction.Ptexpressesdepressivesymptomsincludinginsomnia,

anhedonia,hopelessness,poorinterestor concentration,lowenergy.Patientdeniesanysuicidal/homicidalideationswithintentorplan.

Smartphrases

AdvancedCarePlanning:Patientdoesnothaveanadvanceddirective.

PatienthasanAD.Reviewed,copylocatedinchart.CodeStatus:FullPOLST(PractitionerOrdersforLifeSustainingTreatment):CandidateWhenasked,"WhatshouldHackensackUMCknowaboutyouandyourlovedonesinordertotakebettercareofyou?"*****Assessment:Mr/Ms.***-Currentpainlevelacceptable.-Appearstobehavingunderstandabledifficultycopingaround***-Understandablethemesofloss,sadness,anticipatorygriefnoted.-Likeallpatient/famliesexperiencingseriousillness,Mr/Ms***.andfamilyconfrontseveralemotionalchallengeswhichmaybesupportedwithongoingmonitoring,explorationandsupport.

ACP,Assessment

PlanofCare:-Willcontinuetoexplorewaystoenhanceadaptivesuchascognitive-behavioral,strengths-basedandshorttermtreatmentinterventions-Willcontinuetomonitorpt/familycopingandremainavailableforpsychosocialinterventionaspt/familysystemintegrateillnesstrajectoryandit'simpactontheirlives.-Willcontinuetoliaisewithunitsocialwork/CMandJTCCpsychosocialstafftoensurecommunicationofgoals&preferences,carecoordinationandcontinuity.-Palliativecareeducationongoing;scopeofpracticeandphilosophydiscussed.Palliativecarecontactinformationgiven

PlanofCare

PALLIATIVECAREPSYCHOSOCIALFOLLOW-UPPreferredlanguage:LanguageUsed:SourcesofInformation:Barrierstoassessment:NoneNextofKin(NOK):***PrimaryCaregiver:OtherContacts:***　ChiefComplaint:Iamfeeling***IntervalHistory:ACP:Assessment:PlanofCare:CoreMeasures:　 Yes No PalliativeCareEducation X 　 PastoralCare X　 　 TherapeuticCounseling X 　 AdvancedCarePlanning X　 　X AssessStress X 　 AssessCoping X 　 AssessAnxiety X 　 AssessAnticipatorygrief X 　 FamilyMeeting X　 　X Bio-ethicsconsult X　 　X PCSInterdisciplinaryRounds X 　X

Comparisonw/Teamnotes

Differences

*  Content*  Biopsychosocial

assessment*  Interventions

Similarities

*  OverallFormat(SOAP)*  Integrationofpalliativedomains*  ACP*  DignityQuestion*  CoreMeasures*  PlanofCare

Issue Target/Goal Intervention Measurement

AdjustmentCrisis Emotionalregulation

Psycho-education:SFBT

IRS;practitionerobservation/log;“GoldenQuestion”

Mobilizationfordiseasemanagement

CBT IRS;Clientlog

-StableLivingsituation-FamilyFunctioning:wellbeing

-Resourceidentification&referral;collateralcommunication-Familycounseling

Checklist;clientreportFamilyWellbeingLog

Reducedanxiety,increasedperceivedabilitytomanagestress

CBT IRS;Clientsatisfactionmeasure

RemkeTemplateExample

* “FormethecontactinformationforthepatientiskeyduringintegraltimeswhereIneedaquickreferenceguideonwhotocall.”* “Iusethesocialhxasapromptortalkingpointofgettingtoknowthepatientasaperson.”* “Ialwayscheck:ifyoucompletedadvancecareplanningIwouldpullfromthisandcopyandpasteitintomynotetostaycorrelatedwithyours”* “Ilovethatifyoureadournotesfromadmissionthroughdischargeittellsapatient-focusedpalliativecarestory.”

Whatotherteammembersaresaying:

* ThereisnowdoubtthatSWservicesareimportantineffectivehospice&palliativecare*  LiteraturespecificallycenteredonoutcomesmeasurementofHPCsocialworkinterventionsissparse* Utilizingatemplatemaysupportmonitoringofoutcomesanddatacollection

OutcomesMeasurement

*  What?*  Patient/familyprogressre:theirowngoals*  Clinicianeffectiveness

*  How?*  SWAT*  PIP*  PHQ4orPHQ9*  BeckDepressionScale*  HospitalDepressionandAnxietyScale(HADS)*  CenterforEpidemioligyStudies-Depression(CES-D)Bostonshortform–10items

*  GeriatricdepressionScale(shortform)–15items

What/Howdowemeasure?

* Documentqualityimpactsusefulness* Thereisassociationbetweenstructuralcharacteristics(i.e.template)anddocumentquality* UseoftemplatemayenhancecommunicationandcohesionbetweenHPCsocialworkandtheteam* UseoftemplatemayhighlighttheuniquecontributionsofSWinHPC* Canassistwithbetterpatientoutcomesanddatacollection

Conclusion

Thankyou!

*  TheDignityquestion.(n.d.).RetrivedJan15,2016,fromhttp://dignityincare.ca/en/toolkit.html)

*  Bajgier,J.,Bender,J.,Ries,R.(2012)UseofTemplatesforClinicalDocumentationinPsychiatricEvaluations.BeneficialorCounterproductiveforResidentsinTraining?InternationalJournalofPsychiatryinMedicine,43(1):99-103.

*  Neri,P.M.,Volk,L.A.,Samaha,S.E.,Williams,D.,Fiskio,J.(2014),Relationshipbetweendocumentationmethodandqualityofchronicdiseasevisitnotes.AppliedClinicalInformatics,5(2):480-90

*  Remke,S.(2015).Speakingtheirlanguage:Outcomesforsocialworkpracticeinhospiceandpalliativecare.

*  Shen,S.,South,B.,Butler,J.,Barrus,R.,Weir,C.(2012)TheRelationshipBetweenStructuralCharacteristicsof2010ChallengeDocumentsandratingsofDocumentQuality.AMIAAnnualSymposiumProceedings,1012:848-55

References