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Discharge Summary. Brief Profile Proposal for 20010 - 20011 presented to the PCC Planning Committee Virginia K Saba, EdD, RN & Luann Whittenburg, PhDc, RN-BC, FNP-BC, CPHIMS September 22,2009. The Problem.
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Discharge Summary Brief Profile Proposal for 20010 - 20011 presented to the PCC Planning Committee Virginia K Saba, EdD, RN & Luann Whittenburg, PhDc, RN-BC, FNP-BC, CPHIMS September 22,2009
The Problem • The Current required Medical Discharge Summary does not include Summary Information on the Nursing Patient Plan of Care (PPOC). • No standardized Nursing Discharge Data Set has been established for the Electronic Health Record (E H R ). • Patient (Nursing) Outcomes of the Episode of Illness Care not readily available. • Profile Purpose is to create an electronic summary of the interdisciplinary care processes (focusing on nursing) provided to a patient for the recent Episode of Illness. The profile includes: • Summary of PPOC which includes Outcomes • Status of the PPOC on Discharge • Recommended Follow-up care • This is essential to complete the disposition of the PPOC.
Use Case • PPOC patient with Pneumonia is summarized on Discharge: • Patient was hospitalized for three days and was treated for Nursing Diagnoses: Respiratory Alteration and Acute Pain. • The Expected Outcomes (Goals) were summarized and compared to the Actual Outcomes of the Nursing Diagnoses. • All Nursing Interventions were summarized by concept and Action Types. • The Evaluation of the Care Processes (Nursing Interventions) provide the evidence that nursing and interdisciplinary care was performed successfully. • The follow-up care for the patient to home care in need of Nursing Care, as well as Physical and Occupational Therapy is provided electronically.
Proposed Standards & Systems • SNOMED & LOINC • XDS-MS, CCR, HL7 CDA • ANA Nursing Process – PPOC • ISO reference Terminology Model for Nursing • Clinical Care Classification (CCC) System
Discussion • The Discharge Summary requires PCC nursing effort and can be easily completed during the next year. • Dr. Virginia K. Saba & Luann Whittenburg are willing to act as profile editors. • Vsaba@worldnet.att.net and Lwhitten@gmu.edu • It is critical that the PPOC be carried to conclusion by providing for the Discharge Summary the Nursing Diagnoses, Nursing Interventions, and Nursing Outcomes as part of the Medical Summary and provide at the same time the PPOC status on Discharge and the recommended follow-up care.
