Snow What?
Care Planning
with
SNOMED
INNOVATIONS
‘13
SpeakerSpeaker
Lisa Rabideau, RN, BS, CPAN
Clinical Informatics Manager
CVPH Medical Center
Lisa Rabideau has completed co...
Objectives
 Define Care Planning
 Contrast current care planning
process to future requirements
 Demonstrate use of SNO...
 It is the policy of Corexcel and IMNE to ensure fair balance,
independence, objectivity, and scientific rigor in all pro...
 Open on current site 1926
 Total licensed beds: 409
 313 Acute Care beds

34 Psychiatric/Mental Health beds
 96 Skil...
Nursing Documentation
In the Beginning…
 SOAP
 APIE
 PIE
 Focus
 Graphic flow
sheets
From one extreme to the
other
More Recently…
 Checkboxes
 Data Elements
 Charting by
Exception (CBE)
Need to Strike a Balance
 Data elements for reporting
 Notes to tell the patient story
Nursing Care Plans
 Intended to be plan to provide
care
 Paper or Computerized
 NANDA, NIC, NOC, CCC, PNDS
 Done becau...
According to the “Book”
 Read the nurse’s admission assessment/history and
the medication record
 Review the history, cu...
What really happens:
 Assessment generates standard
problem
 Nurse reviews problems and chooses
plans
 Plans are pre-se...
Takes up space
Annoys providers
Influencing the Transition…
 Meaningful Use Stage 1
 The number of patients … who have at least one
entry (or an indicat...
Moving from Nursing Care
Plans to Interdisciplinary
Problem List/Plan of Care
 Currently used by Nursing
 Consult orders...
Initial Step
 Took list of existing Nursing
Care Plan Problems
 Found appropriate SNOMED
problem
 Re-mapped and re-name...
Example of Crosswalk
Current Problems in
Test
Current Problems in
Prod
SNOMED options
Knowledge deficit of
community resou...
Problem Name Mapping
Problem SNOMED
Nutrition Deficit Risk Nutrition Impairment
Injury Risk Fall Risk
Fluid Volume Impairm...
Problems not in
“Starter Set”
 Entrapment Precautions
 Elopement Precautions
 Comfort Care, Dying Process
(added manual...
Care Plan Orders
 Met with sub-group of Nursing
Documentation Team
 Edited care plan orders to
minimize duplication,
red...
CPOE Order Sets
 Contain Nursing Orders for
appropriate problems.
 Use of Nursing “Protocols”
 Drive “Problem Order” to...
Protocol Content
A. Assessment:
1. Assess the location, radiation and duration of pain.
2. Assess intensity of pain on sca...
Other Nursing Measures
 Addressed in Order Sets
 Addressed in Standards of Care
Comfort Care CPOE Order
Set
Standards of Care
 Use Marker Model of structure,
process and outcome standards
 Address nursing process (APIE),
Basic n...
Move to Interdisciplinary
Plan of Care
 Using plan of care display for
multidisciplinary rounds
 Start with Respiratory ...
EDIS & Provider
Documentation
 Problem list now populated with
both nursing and medical
problems
 Sometimes the same
 L...
 Problems populated list
 Plans need to be selected if appropriate
 Open problem to see source
 In this case it is Primary Complaint
 When note charted from
problem, problem name is
attached to note
Problems Needing Care
Plan Orders
 Pneumonia
 Heart Failure
 DKA
Resources
 AHIMA Workgroup. "Problem List Guidance in the EHR."
Journal of AHIMA 82, no.9 (September 2011): 52-58.
 CVPH...
Soarian Clinical Solutions Track 2
Session # 11
Thank you for attending
this session.
Please take a few moments to complet...
Care planning presentation 13
Care planning presentation 13
Care planning presentation 13
Care planning presentation 13
Care planning presentation 13
Care planning presentation 13
Care planning presentation 13
Care planning presentation 13
Care planning presentation 13
Care planning presentation 13
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Care planning presentation 13

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Discussion of Care Planning using SNOMED-CT codes and terminology

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  • Beginning of multi phased documentation reduction plan to get nurses out of the computer and focused on the patient while documenting essential information in a usable way. Systematized Nomenclature of Medicine - Clinical Terms Explain the path we are on toward Interdisciplinary documentation and planning care
  • Located in far northern NY near the Canadian border. Just across Lake Champlain from Burlington VT. Lake Champlain was the 6 th Great Lake for about a day.
  • First Building open in 1926 Physician’s Hospital, Merged with Champlain Valley hospital, run by the grey nuns, (opened in 1910), in 1967 CV hospital closed in 1972 and pts transferred to new addition, renamed Champlain Valley Physicians Hospital, CVPH. Plattsburgh State University purchased CV building
  • This licencing info is from 2012, but 2013 brought some changes to skilled nursing beds,
  • Documentation like many other things has been on a pendulum. Many years ago documentation was all narrative Subjective, objective, assessment plan Assessment , plan, intervention, Evaluation Problem (by number) Intervention, evaluation Focus on positive, progress toward goal Graphs of vital signs, I & O, meds Swung toward structured data that can be reported and easy to chart, but don’t show the whole picture. 3 pts with same checks totally different clinically.
  • NANDA- North American Nursing Diagnosis Association NIC- Nursing Intervention Classification NOC- Nursing Outcome Classification CCC- Clinical Care Classification , VIrginia Saba, care componenets PNDS- Perioperative Nursing Data Set What is a nursing diagnosis? A nursing diagnosis is a clinical judgment about actual or potential individual, family, or community experiences/responses to health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability. A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human response to actual or potential health problems and life processes.  For example, a medical diagnosis of Cerebrovascular Attack (CVA or Stroke) provides information about the patient’s pathology. The complementary nursing diagnoses of Impaired verbal communication, risk for falls, interrupted family processes and powerlessness provide a more holistic understanding of the impact of that stroke on this particular patient and his family – they also direct nursing interventions to obtain patient-specific outcomes.
  • Multiple entries of “Care Plan Reviewed” with no other information in the note. Frustrating and useless to the Provider and other clinicians.
  • ICD- International Classification of Diseases, AMA used for billing. Move toward 10 which the rest of the world is using. Transitions of Care – Summary of care transmitted electronically. “ We proposed to describe transitions of care as the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.”
  • Done by myself and CMIO
  • Differences between test and prod environment in list of problems used for care plan.
  • There were a couple of current nursing problems that didn’t have a corresponding match in our starter set. Using Risk of elopement for cognitvely impaired subject (observable entity) [439166003] Dying process (observable entity) [399069006]
  • Nursing Documentation team working one 3 initiatives: Decrease admission and shift assessment length Improve care plan process Pertinent clinical notes
  • Duplication comes from many sources: Order sets, not discontinuing duplicate orders. Putting orders for things contained in a nursing protocol. Use the Marker Model of standards. Structure, process and outcome standards. 1988 Carolyn Smith-Marker Protocols are a process standard requiring nursing thought and judgement. Have embedded an “order” for the problem in order sets that is driven by workflow to the problem list.
  • Previous care plan order set for Chest pain.
  • Current orders decreased to orders for the appropriate protocols.
  • Those nursing measures not addressed in a protocol format are either part of the unit standard of care or are added to problem specific order sets.
  • Each unit/specialty defines standards for assessment, reassessment and the other needs. Critical care, perioperative services, Med-surg
  • Currently DP documenting notes in Softmed (3M) which we have pointers to in Soarian. Hisotorically not discoverable, no longer true. Move them to Soarian. Als plan to get Resp Therapists to put pertinent notes from plan of care problem. Accurate picture of patient condition requires a full “patient story” Rush University developing pt story display, similar to clinical summary to show things pertinent to pt on one screen- pt home page. Includes problems, diagnoses, nutrition, upcoming tests (itnerary), as well as nursing info on current lines, airway, drains, wounds issues.
  • Example of clinical note initiated from plan of care
  • Actual display of clinical notes from a patient.
  • In this case nursing documentation has generated problems for this patient based on past medical history of CAD and Cloitis and the presenting complaint of Abdominal pain
  • Search on Abdominal pain brings up pain choices, nurse could choose Acute pain plan to apply
  • The nurse can then go to create a plan of care, enter the problem and see what plans are available to use, or add nursing orders individually.
  • Pneumonia is the first problem being driven to the problem list from an order set. Next will be heart failure. Not using interventions except for post op vitals, will drive interventions from the plan of care for data elements that need reporting or things important not to forget. DKA order set driving 2 problems: Diabetes and DKA. The DKA may resolve but the pt will still be diabetic.
  • Care planning presentation 13

    1. 1. Snow What? Care Planning with SNOMED INNOVATIONS ‘13
    2. 2. SpeakerSpeaker Lisa Rabideau, RN, BS, CPAN Clinical Informatics Manager CVPH Medical Center Lisa Rabideau has completed commercial bias disclosure forms and do not have any conflicts of interest.
    3. 3. 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
    4. 4.  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.
    5. 5.  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
    6. 6. Nursing Documentation In the Beginning…  SOAP  APIE  PIE  Focus  Graphic flow sheets
    7. 7. From one extreme to the other
    8. 8. More Recently…  Checkboxes  Data Elements  Charting by Exception (CBE)
    9. 9. Need to Strike a Balance  Data elements for reporting  Notes to tell the patient story
    10. 10. 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
    11. 11. 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.
    12. 12. 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.
    13. 13. Takes up space Annoys providers
    14. 14. 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
    15. 15. 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
    16. 16. Initial Step  Took list of existing Nursing Care Plan Problems  Found appropriate SNOMED problem  Re-mapped and re-named problems
    17. 17. 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
    18. 18. Problem Name Mapping Problem 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 Deficit Therapeutic Regimen- Diabetes Diabetes Mellitus Chest Pain Acute Chest Pain Comfort Care Dying Process
    19. 19. Problems not in “Starter Set”  Entrapment Precautions  Elopement Precautions  Comfort Care, Dying Process (added manually)  Restraints
    20. 20. 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
    21. 21. CPOE Order Sets  Contain Nursing Orders for appropriate problems.  Use of Nursing “Protocols”  Drive “Problem Order” to Plan of Care
    22. 22. Protocol Content A. 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.
    23. 23. Other Nursing Measures  Addressed in Order Sets  Addressed in Standards of Care
    24. 24. Comfort Care CPOE Order Set
    25. 25. 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)
    26. 26. 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”
    27. 27. EDIS & Provider Documentation  Problem list now populated with both nursing and medical problems  Sometimes the same  Learning curve for nursing and providers
    28. 28.  Problems populated list  Plans need to be selected if appropriate
    29. 29.  Open problem to see source  In this case it is Primary Complaint
    30. 30.  When note charted from problem, problem name is attached to note
    31. 31. Problems Needing Care Plan Orders  Pneumonia  Heart Failure  DKA
    32. 32. 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.
    33. 33. Soarian Clinical Solutions Track 2 Session # 11 Thank you for attending this session. Please take a few moments to complete your evaluation form before you leave. Presentations can be downloaded at: www.usa.siemens.com/InnovationsIT

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