INTRODUCTION OF THE STANDARDISED INITIAL ASSESSMENT, CARE PLANNING AND REFERRAL DOCUMENTATION

1. INTRODUCTION OF THE STANDARDISED INITIAL ASSESSMENT, CARE PLANNING AND REFERRAL DOCUMENTATION Med/Surg Division, Christchurch Hospital February 2011

2. PROGRAMME

3. Overview and Endorsement • Leaders/mentors • Standardisation • Documentation compliance • Patient centred • User friendly

4. Website Address Intranet • Our organisation (bottom left of home page) / Divisions / Medical Surgical (Christchurch Hospital) / Assessment and Care Planning Documentation (second to bottom on blue navigation bar) Internet • http://www.cdhb.govt.nz / Facilities (on black navigation bar) / Hospitals / Christchurch Hospital / Nursing – Christchurch Hospital / Assessment and Care Planning Documentation (second to bottom on navigation bar)

5. Patient Questionnaire Tips on what to say when handing out the questionnaire: • This form is to help us plan your care while in hospital and can be completed with or by your family/whanau • There is no obligation to complete all the sections • When you are finished with the Questionnaire please hand it back to nursing staff or the Ward Clerk

6. Patient Questionnaire

7. Patient Questionnaire

8. Risk Screening Tool Second page

9. Risk Screening Tool Second page

10. Initial Assessment

11. Nutrition Section (p4)

12. Care Planning This is split into 2 sections: • Weekly Care Plan and 7 day Risk Management Plan • Daily Care Plan

13. Weekly Care Plan

14. 7 Day risk Management Plan

15. Daily Care Plan

16. Daily Care Plan

17. Referral Form

18. Referral From

19. EXPECTATIONS OF WHEN THE FORMS ARE COMPLETED AND BY WHOM

20. ED, AMAU, SARA, Day Units Nursing Staff All patients over 16 yrs presenting to hospital (apart from Outpatient Clinics) must have a Risk Screening tool completed within the first 6 hours of presentation. To assist in the completion of this form it helps to have the patient complete the questionnaire. It will help for Outpatient staff to be aware of the risk screening tools – a poster of the screening tools is available Patients who are going home • Fully complete Risk Screening Tool and actions beforehand • File within patient’s documentation Patient s admitted - File Risk Screening Tool (and if used the Patient Questionnaire and Referral form) in the front cover of the clinical notes and send to the inpatient ward/unit.

21. Options for incorporating these documents in your existing documents • The patient questionnaire and risk screening form may be appropriate to complete at pre assessment clinic –some are already doing so • When revising any of your specialist clinical pathways consider adding this content into them

22. AMAU and SARA Nursing Staff If patient is likely to stay in AMAU or SARA for longer than 24 hours. • Ensure all previous actions in the documentation have been completed. • Commence the Care Assessment and planning booklet • Commence the Weekly Care Plan /Risk Management Plan within the Care assessment and planning booklet. • Commence the Daily Care Plan (for your shift only) within the Care Assessment and Planning booklet

23. In patient Ward/Unit Nursing Staff When patient admitted • Review what documentation and actions have been completed • Action what has not been completed and document accordingly • Start the documentation if it is obvious it has not been commenced yet

24. In patient Ward/Unit Nursing Staff (continued) Each shift Weekly Care Plan • Review Weekly Care Plan and update as required. Check the date the Weekly Care Plan commenced and complete new plan if required i.e. every 7 days. • Ensure risks have been reassessed and updated on the Risk Management Plan (located on the back of the Weekly Care Plan) within the last 24 hours. If there has been no documentation of risk reassessment within the last 24 hours, complete this section. Use O, D, or N/A and sign this section to denote review. Daily Care Plan • Review previous shift’s management plan, make amendments as appropriate within your shift column. If there has been no change to a patient’s management strategy from the previous shift, document “NC” in the corresponding management strategy space within your shift column.

25. FILING

26. Standardised Filing Format • File the complete documentation package including the Care Assessment and Planning booklet, in the front of the patient’s clinical notes after the MR2 and other essential forms such as NFR. • Daily Care Plans for the next 6 days are to be filed within the booklet on top of the previous Daily Care Plan. • Clinical/progress notes are to be filed after the Care Assessment and Planning booklet for that week. • When a new Weekly Care Plan is commenced, place this document under the progress/clinical notes currently being used (see file mock up)

27. SPECIALITY NEW/HIGH RISK SECTIONS Smokefree Fall Prevention Alcohol Screening Pressure Injury Malnutrition screening Cognitive Screening – CAM, MSQ Mental Health – Kessler

28. SMOKEFREE Supporting health professionals to deliver effective smoking cessation

29. Introduction Smokefree is about:- • Identifying smoking status • Informing about CDHB Smokefree Policy • Providing advice to quit • Providing timely NRT to smokers to manage their nicotine dependence in a smoke free environment • Providing Quitpack and / or Quitcard / referral for smoking cessation • DOCUMENTING all of this

30. Definitions Definitions • Current Smoker – has smoked at least one cigarette in the last month • Never smoker – has not smoked more than 100 cigarettes in their life-time • Ex smoker – have smoked more than 100 cigarettes in their life-time but have not smoked in the last month Key Points • Check the patients smoking status is correct in relation to these definitions – change the documentation if req. • If they are a recent ex-smoker, they may still require NRT / support • For patients who are ‘never smokers’, tick the “No Risk Identified’ boxes – no further action required

31. If they smoke • Advise that CDHB buildings and grounds are smokefree • Provide brief advice – this can be as little as a 30 sec intervention, preferably tailored individually • Offer Nicotine Replacement Therapy (NRT) as soon as possible (NRT is most effective when administered before cravings set in) For patients not admitted to wards • Provide advice to quit • Provide Quitpack / Quitcard / prescription • Refer to community cessation provider

32. Care Planning • If an inpatient initially declines NRT – continue to offer NRT • Emphasise that this for them to remain Smokefree during their stay, even if they do not want to quit – document if it was accepted and charted, or declined

33. Care Planning Risk Management Plan • Identify and document daily nicotine dependence issues and the management for this • In the hospital environment NRT therapy is an ongoing requirement for nicotine dependence

34. Withdrawal symptoms • Irritabilty/mood changes • Headaches • Urges to smoke • Depression • Restlessness • Poor concentration • Increased appetite • Sleep disturbance • Decrease in heart rate • Increase skin temperature • Mouth ulcers • Constipation

35. Care Planning Daily/shift care plan • Document NRT requirements in ‘Patient / Area Specific’ box • Monitor craving levels and titrate medications

36. Care Planning cont. Cravings can be a result of under-dosage – signs are irritability, sleep disturbance, urges to smoke, depression, increased appetite, anxiety, restlessness, mouth ulcers etc. Titration – increase dose by providing higher strength patches or co-therapy (additional lozenges / gum) Over-dosage– symptoms of overdose are rare (e.g. nausea, heart palpitations etc) and can be addressed by removing the patch, using a lower strength patch or using only lozenges / gum

37. Referral Form • Fill in referrer’s details at top of form and information required under ‘External Smoking Cessation Services’ • Ensure that patient has given consent for referral • Ensure that patient’s contact number is included • Identify cessation service in consultation with patient • Ensure that patient ID label is put on this side of the referral form • Fill in ethnicity • Fax to cessation service • Note: ensure that you have documented the referral on the Care Assessment and Planning form (‘external referral sent’)

38. FALL PREVENTION

39. ALCOHOL SCREENING TOOLS

40. ALCOHOL AMOUNTS The patient should be asked about the quantity of alcohol the patient consumes: in an open and non-judgemental manner

41. CAGE/CRAFFT

42. Pressure Risk Assessment and Management

43. Pressure Risk Assessment and Management • Current or Previous healed Pressure Ulcer - > high risk • Incident Reporting Line - 86999 at CH • ALWAYS use BOTH Clinical Judgment and Braden Scale

44. Staging Stage 1

45. Staging (continued) Stage Two

46. Staging (continued) Stage 3

47. Staging (continued) Stage four

48. Pressure Risk Assessment and Management (continued) Patient Questionnaire: • Flags: Wound or Skin breakdown – ? Cause – is it pressure -> High Risk Care Assessment and Planning – Initial Assessment • Check skin • Tailor interventions and resource requirements to their risk level or potential for deterioration Weekly Risk Management Plan • Document Individualised strategies based on skin and Risk Assessment • Daily review and increase or decrease strategies respectively – with rationale • Provide a rationale if the Braden Scale in your opinion, provides an inappropriate risk level. Daily Care Plan • If Pressure injury has ulcerated document under Wound Dressings and write PI Prevention strategies under Patient specific area and sign. • If patient at Risk or Stage 1 injury then write PI Prevention strategies under Patient specific area and sign. • Document variances in clinical notes

49. Pressure Risk Assessment and Management (continued) IMPORTANT DO NOTS: • Massage over reddened bony prominences • Use Donut type devices • Avoid drying the skin

50. Malnutrition Screening Tool (MST)