presented by uic-con. state the importance of documenting risk. describe how identification of...
TRANSCRIPT
What’s New about the Risk Inventory?
Presented by UIC-CON
Objectives
State the importance of documenting risk.
Describe how identification of risk impacts the delivery of quality care and improves outcomes.
Identify the differences between the old and new risk inventory.
Explain the expanded content areas covered in the risk inventory.
Construct a risk inventory on a participant.
Why should I assess & document risk?
To maintain participant’s safety and quality of life.
To create awareness of participants’ risks among the care team.
To develop a mitigation plan addressing preventable incidents.
To identify additional supports and/or services required.
To prioritize risk based on severity of harm. To evaluate a mitigation plan based on changing
risk.
When should I assess & document risk?
Pre-transition o Complete baseline (MFP requirement)o Revise as needed, based on change(s) to
the participant’s condition Post-transitiono Review at least monthlyo Revise as needed, based on change(s) to
the participant’s condition
How do I assess & document risk?
Complete assessment. If your agency does not have a formal
assessment, a demonstration on how to convert the risk inventory into an assessment will be presented.
Complete MFP Risk Inventory based on findings from your assessment. May need to expand assessment based on new
areas on the risk inventory.
What content is covered in the Risk Inventory?
80 questions, 10 domains Physical Health Behavioral and Emotional Health Substance Abuse Self-Harm or Harm to Others Cognition Medication, Laboratory, and Utilization Functional: ADLs & IADLs Environment Interpersonal and Social Supports Engagement, Self-Management, Recovery
Domain I: Physical Health Representation of major body
systems: circulatory, respiratory, digestive, intestinal, urinary, etc.
Includes additional questions on pain, wounds, sleep, falls, burns, etc.
Assess participant’s knowledge of disease management.
Assess for presence of acute physical symptoms (a good indicator of disease management).
Domain II: Behavioral and Emotional Health
Assess for presence of acute behavioral or emotional health symptoms (a good indicator of disease management).
Symptoms identified include disorganized thought processes, false sensory perceptions, social withdrawal, mood changes, anxiety, etc.
This domain focuses on presence of symptoms rather than self-management of disease.
Domain III: Substance Abuse
Assess for current signs of substance abuse and risk for relapse.
Assess for history of substance abuse.
Domain IV: Self-Harm and Harm to Others
Assess for history or current engagement in criminal activity (i.e., arson, gang activity, property destruction).
Assess for history or current engagement in risky behaviors (i.e., unhealthy sexual practices).
Assess for history of suicidal and/or homicidal behavior.
Assess for history or current vulnerability for abuse, neglect, or exploitation.
Domain V: Cognition
Assesses for presence or risk of diminished cognitive functioning resulting in impaired judgment, impaired problem solving ability, or lack of orientation.
Domain VI: Medication, Laboratory, & Utilization
Assess participant’s knowledge, ability, and adherence to medication management.
Assess for lack of primary care services.
Assess for frequent utilization of emergency services.
Domain VII: Functional
Assess participant’s ability to perform Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs).
Assess need and proper use of assistive and adaptive devices.
Domain VIII: Environment
Assess participant’s home and neighborhood for accessibility and safety (e.g., accessibility of home, availability of community resources).
Domain IX: Interpersonal & Social Supports
Assess engagement and quality of interpersonal relationships (e.g., presence of social support system, healthy interactions).
Domain X: Engagement, Self-Management, & Recovery
Assess engagement in plan of care (e.g., motivation, trust, interest, understanding, historical success).
Identify barriers that negatively affect plan of care.
How do I translate my assessment findings into the risk inventory?
Each question is equivalent to a risk. Check ‘Yes’ if risk was identified Check ‘No’ if risk was not identified For each risk identified, you will be asked to
“Describe why this is a risk for the participant” – This is where you enter data from your assessment.
Then, you will be asked (for each risk identified) to “Describe how this risk will be mitigated before and after transition” – This is your mitigation plan.
In the mitigation plan, you are asked to develop individualized strategies to mitigate a known risk using an action verb (i.e., evaluate, educate, coach, arrange, coordinate, etc.).
Recap
Risk Inventory is a tool used to organize assessment findings into specific content domains.
Conducting a comprehensive assessment is significant to risk identification.
Developing tailored strategies specific to the participant is consequential to risk mitigation.
Documenting Case Notes: Using the SOAP Method
Presented by UIC-CON
20
Objectives
At the end of this session, the learner will be able to:
Define the importance of documenting case notes.
Describe the SOAP method for documenting case notes.
Illustrate when, where, and how to document a case note.
Construct a case note in the MFP CRM Web Application.
21
Why should I document case notes?
Keeps provider(s) abreast on current treatment plan and ongoing developments
Provides the care team with a mechanism to communicate with one another
Supports an action by demonstrating providers’ engagement with participant
Provides a representation of the participant and his/her progress before and after transition
22
When should I document a case note?
After a home visit with an MFP participant and/or caregiver
After a phone call with an MFP participant and/or caregiver
After an office visit with an MFP participant
Documentation of case notes is ongoing, pre- and post-transition.
23
Where do I document a case note?Use the notes feature to document contacts.
Click the “+” sign to add a new note (upper right hand corner).
24
How should I document a case note?
Select Contact Date Select Contact Type:
Face-to-face visit Phone call Email Fax Other
Select Location: Participant’s home TC’s office Hospital/Institutional care setting Service Provider’s Office (i.e.,
psychiatrist) Community Provider (i.e., day program) Other
25
How should I document a case note? Select Persons Contacted (Select All):
Participant Family/Guardian/Significant Other/Power-of-Attorney for Health Care Physician Hospital Staff (e.g., nurse, social worker, discharge planner) Facility Staff Community Provider/Worker/Case Manager Other Community Based Persons (e.g., friend, lawyer) Other
Enter a SOAP Note for contact: Subjective findings Objective findings Assessment findings Plan Other Notes
26
Definition & Purpose of a SOAP note
DefinitionAn organized method of documentation used by providers to describe events involving the participant.
PurposeThe SOAP note format is used to facilitate effective communication among the care team by providing assessment findings, identifying problem(s), and developing action plan(s).
27
Subjective findings
Describe how the participant feels. Example: Jack reports he is “feeling well and has no
concerns.”
Document what the participant says about his/her current living situation. Example: Susan reports she is “happy, healthy and
enjoying her new apartment.”
Record participant’s exact words to describe his/her health. Example: John reports he has a “dull headache” and it has
lasted over a week.
Document any mention of changes to his/her medications, diet, activity level, etc. Example: When Sarah went to visit her family doctor this
week, he told her she had “high blood pressure and added a new medication.”
28
Objective findings
Document objective data including blood pressure and/or blood glucose readings, and findings from physical assessment (i.e., noticeable scraps or cuts, tearfulness, etc.). Example: TC checked Henry’s blood
pressure log and found his last three readings were all within normal limits, 122/78, 120/76, and 122/80.
29
Assessment findings
Document your interpretation of the subjective and objective findings. Example: Courtney met with a dietician
last week to discuss how to follow a diabetic diet. Courtney stated an understanding and compliance with following a diabetic diet. However, her personal assistant reported that Courtney was eating a ½ gallon of ice cream weekly and drinking a 2L of pop daily.
30
Plan Document plan on addressing assessment finding (address each
abnormal finding). Example: Create food diary with Courtney and follow-up
weekly. Take Courtney grocery shopping weekly and teach her how to read food labels and choose healthy foods.
Report any issues or barriers to implementing this action plan. Example: The nearest grocery store with a variety of fresh
fruits and vegetables is 45 minutes away.
Document follow-up to action items. Example: TC re-visited Courtney a month later and found her
blood glucose readings were consistently over 200 mg/dl. TC will arrange for Courtney to meet with her dietician and primary care provider to discuss strategies to improve diabetic management.
31
Case Study
Ruth is a 47-year old female who has resided at We Care nursing facility for the past two years. Her admitting diagnosis was major depressive disorder, alcohol abuse and paraplegia.
At the time of her admission, Ruth was involved in a motor vehicle accident while driving under the influence of alcohol. She was not taking any medications and consumed a 24-pack of beer weekly for 15 years.
Ruth’s medical history includes hypertension, chronic liver disease, chronic renal disease, secondary hyperparathyroidism, hepatic encephalopathy, and paraplegia. She is taking eight different medications for her physical and mental health. She uses a motorized wheelchair for mobility.
Ruth has stabilized at We Care and is excited about moving into her own apartment.
32
Exemplar: Pre-TransitionPhysical Health Domain
33
Exemplar: Pre-TransitionSubstance Abuse Domain
34
Exemplar: Pre-TransitionInterpersonal and Social Supports Domain
35
Exemplar: Pre-TransitionFunctional Domain
36
Exemplar: Post-Transition Contact On: 8/24/14 Contact Type: Face-to-face contact Location: Participant Home Persons Contacted: Participant SOAP Note
Subjective findings: Ruth stated, “I hate living here and want to move.” Objective findings: Ruth was tearful and in distress. Assessment findings: This is her first week living in her new apartment.
Ruth has a history of depression and is prescribed Zoloft 50 mg in the evening. Her support system is sparse. She is connected with a community psychiatrist and counselor.
Plan: Discuss what she likes and dislikes about her apartment. Develop strategies on how improve her current living situation. Inquire about medication compliance and substance abuse. Administer depression screening tool and compare findings to baseline results. Provide Ruth with a crisis hotline number. Offer to sit with Ruth while she calls her counselor, if needed. Offer to take Ruth on a community outing, if she desires. Follow-up with Ruth the next day via phone.
37
Exemplar: Case Note
Conclusion
Questions? Please contact your UIC Pod Leader
with any questions.
38
UIC College of Nursing
DRSCarla TozerBrian O’Sullivan
312-996-7494217-586-6039
[email protected]@uic.edu
DOAValerie GrussRyan Reid
312-996-2193217-586-6039
[email protected]@uic.edu
DMHDennis CrowleyMike BerkesJustin Wesley
217-586-6039 [email protected]@[email protected]
DDDCarrie BergerJustin WesleyJason Immertreu
217-586-6039
312-996-7643