Download - Care planning presentation 13
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Snow What?
Care Planning
with SNOMED
INNOVATIONS ‘13
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SpeakerSpeaker
Lisa Rabideau, RN, BS, CPAN
Clinical Informatics ManagerCVPH Medical Center
Lisa Rabideau has completed commercial bias disclosure forms and do not have any conflicts of interest.
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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
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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.
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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
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Nursing DocumentationIn the
Beginning… SOAP APIE PIE Focus Graphic flow
sheets
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From one extreme to the other
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More Recently…
Checkboxes Data Elements Charting by
Exception (CBE)
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Need to Strike a Balance
Data elements for reporting Notes to tell the patient
story
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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
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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.
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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.
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Takes up space Annoys providers
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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
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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
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Initial Step
Took list of existing Nursing Care Plan Problems
Found appropriate SNOMED problem
Re-mapped and re-named problems
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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
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Problem Name MappingProblem 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 DeficitTherapeutic Regimen- Diabetes
Diabetes Mellitus
Chest Pain Acute Chest Pain
Comfort Care Dying Process
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Problems not in “Starter Set”
Entrapment Precautions Elopement Precautions Comfort Care, Dying Process
(added manually)
Restraints
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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
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CPOE Order Sets
Contain Nursing Orders for appropriate problems.
Use of Nursing “Protocols” Drive “Problem Order” to
Plan of Care
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Protocol ContentA. 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.
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Other Nursing Measures
Addressed in Order Sets Addressed in Standards of
Care
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Comfort Care CPOE Order Set
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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)
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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”
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EDIS & Provider Documentation
Problem list now populated with both nursing and medical problems
Sometimes the same Learning curve for nursing
and providers
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Problems populated list Plans need to be selected if
appropriate
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Open problem to see source In this case it is Primary
Complaint
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When note charted from problem, problem name is attached to note
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Problems Needing Care Plan Orders
Pneumonia Heart Failure DKA
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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.
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Soarian Clinical Solutions Track 2 Session # 11
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Presentations can be downloaded at:
www.usa.siemens.com/InnovationsIT