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  1. 1. UTHCPC Policies and Procedures Patient Care – Treatment Services Chapter 3 Treatment Services Sections Interdisciplinary Patient Assessment Nursing Admission Assessment Psychosocial Assessment Patient and Family Education Assessment Admission History and Physical-Initial Psychiatric Examination Pain Management Master Treatment Planning/Review Process Abuse and Neglect Assessment Responsibilities Abuse and/or Neglect Assessment Criteria Therapeutic Recreation Assessment Music Therapy Assessment Interpretation Services Chaplain Assessment Services Psychology Services Nutritional Assessment/Services Pharmacy Services Social Services Group Process Pet Visitation Program Closed Circuit Telecasting Continued on next page Printed 01/30/15 3-1
  2. 2. UTHCPC Policies and Procedures Patient Care – Treatment Services Sections, Continued EKG Process EEG Request Nuclear Medicine Testing Progress Notes Social Service Case Management Progress Notes Social Service Group Progress Notes Physician’s Orders Electroconvulsive Therapy (ECT) Clozapine Therapy Patient Request for Physician Change Withholding Resuscitation or Life- Sustaining Treatment Request for Autopsy Seclusion/Restraint Process Philosophy of Limiting Seclusion/Restraint Use Medication Orders Automatic Stop Use of PRN/NOW Psychoactive Medications Medication Usage Evaluation Prescription Blanks for Discharged Patients Controlled Drug Number/DEA # Drug Formulary Reporting Adverse Drug Reactions Prescription Assistance Program Consent to Treatment with Psychoactive Medication Patient Rights for Court- Ordered Psychoactive Medication Treatment Classes of Medication Requiring Consent Temperature Measurement using the IVAC Thermometer Sterile Dressing Application Specimen Collection from a Wound for Culture Glucose Monitoring System 3-2 Printed 01/30/15
  3. 3. UTHCPC Policies and Procedures Patient Assessment upon Admission Patient Care – Treatment Services Interdisciplinary Patient Assessment Summary Date of Last Review 02/12/04 SME: Dr. Roy Varner To ensure quality patient care, core disciplines assesses each patient admitted to the hospital within designated timeframes. Disciplines The following table identifies when each discipline assesses the patient upon admission: Discipline When Registered nurse Within 8 hours. Re-attempts to assess the patient must occur every 24 hours after the initial attempt until the assessment is complete or patient discharges. Physician Within 24 hours. Re-attempts to assess the patient must occur every 24 hours after the initial attempt until the assessment is complete or patient discharges. Social service clinician Within 72 hours of admission. Re-attempts to assess the patient must occur every 24 hours after the initial attempt until the assessment is complete or patient discharges. Documenting assessment completion The Interdisciplinary Initial Assessment Cover Sheet is used to document initial and ongoing attempts to complete the assessment process. Identified critical assessment The physician and treatment team must consider the identified critical assessment trigger areas that are reflected on the multidisciplinary problem aggregate for inclusion in the Master Treatment Plan. Educational needs The nurse and social service clinician identify/address the educational needs using the Patient/Family Education section. Assessment instructions Specific assessment instructions for each discipline may be found in the discipline- specific assessment procedures. Form Interdisciplinary Patient Assessment form Related standards JCAHO PE 1-1.3-1.6.1.1, PE 1.8, PE 3-3.1, PE 5-8, PE 4-4.3 JCAHO MS 6.2 Printed 01/30/15 3-3
  4. 4. Patient Assessment upon Admission UTHCPC Policies and Procedures Patient Care – Treatment Services Nursing Admission Assessment Completion responsibility Date of Last Review 4/12/04 SME: Arslee Mackey A registered nurse (RN) must complete the Nursing Initial Admission Assessment/Data form or the Intake Screen/Nursing Reassessment form within 8 hours of admission. 1.0 The RN completes the appropriate Nursing Assessment Document. 1.1 The Nursing Initial Admission Assessment/Data form shall be completed on all new patients as well as patients who have been discharged more than (30 days). 1.2 The Nursing Intake/ Reassessment form (brief assessment) shall be completed on patient’s who have been discharged 30 days or less and have a previously completed Nursing Initial Admission Assessment/Data form. 1.2.1 A legible copy of the previous Nursing Initial Admission Assessment/Data form shall be placed in the patient’s medical record filed behind the Nursing Intake/Reassessment form 2.0 If the patient refuses to be examined or is unable to be examined because of the symptoms of mental illness, initial attempt/reassessment attempts must be documented on the Interdisciplinary Initial Assessment Cover Sheet within 8 hours and every 24 hours thereafter until the assessment is completed. 2.1 Reassessment information obtained must be entered on the Nursing Initial Admission Assessment /Data form or the Nursing Intake/ Reassessment Form instead of the progress note. 3.0 The RN must enter all positive findings from the assessment on the Multidisciplinary Problem Aggregate (MPA). 4.0 The registered nurse initiates a nursing plan of action as appropriate prior to formulation of the Master Treatment Plan (MTP). Elements The following are elements of the Initial Nursing Assessment form: • Admission Data • Hygiene and Sleep Patterns • Alcohol/Drug History • Educational Data • Functional Screen • Fall Risk Assessment • Physical Assessment • Pain Assessment • Psychiatric Assessment • Nutritional Screen • Patient/Family Education • Initial Plan of Care 3-4 Printed 01/30/15
  5. 5. UTHCPC Policies and Procedures Patient Assessment upon Admission Patient Care – Treatment Services Continued on next page Printed 01/30/15 3-5
  6. 6. Patient Assessment upon Admission UTHCPC Policies and Procedures Patient Care – Treatment Services Nursing Admission Assessment, Continued Admissions data • Body/Safety Search (a licensed staff member must be present during the process) to observe the following: – The skin integrity – Skin markings such as bruising, decubitus, scars, tattoos, pain, physical findings suggestive of abuse/neglect, etc. Location of markings: A diagram of a body figure is provided on the form to indicate the location and code the observations. – Contraband items found on search and the disposition of those items • Chief Complaint – Recorded in patient’s own words (is not a medical diagnosis) • Current Medication - Licensed staff gather information regarding patient’s current/previous medication use. The registered nurse assesses the patient's use of current medication to determine his/her need to continue a certain medication due to untoward effects of abruptly discontinuing medications. RN conveys information to the physician. Hygiene and sleep pattern(s) Data to be collected by licensed staff • Bath habits • Oral care • Usual sleep/rest patterns • Aids used for relaxation Alcohol/drug history Data to be collected by licensed staff • Collects information regarding alcohol and drugs prior to admission • Collects data regarding withdrawal symptoms Educational data Purpose: Licensed staff collects educational data The registered nurse completes/reviews the educational data in an effort to identify how the patient's learning activities should be structured based on the following: • Cultural, dietary, or religious considerations • Preferences • Barriers • Readiness to learn Functional screening The registered nurse assesses the patient for the following: • Ability to care for self and live independently • Level of ability to perform ADL's • Current functioning Continued on next page 3-6 Printed 01/30/15
  7. 7. UTHCPC Policies and Procedures Patient Assessment upon Admission Patient Care – Treatment Services Nursing Admission Assessment, Continued Fall risk The RN assesses all patients for fall risk as follows: • Marks the box indicating Initiate Fall Precautions if the patient is a potential risk Score: A score of 5 or above indicates that the patient is at a potential risk for falls. • Marks the box indicating Assessed – No Risk Factors for a score of 4 or less. • The RN trigger Fall Risk to MPA as appropriate Physical assessment The RN assesses the patient’s systems through both observation and interview and notes by placing an “X” in all boxes that apply. Systems to be assessed include the following: • Central nervous • Respiratory including date of TB testing • Cardiovascular • Gastrointestinal • Genitourinary • Endocrine • Musculoskeletal Pain assessment The RN completes pain assessment section. Psychiatric assessment The registered nurse assesses the patient’s presenting level of mental and behavioral functioning through observation and questioning and note by placing an “X” in all boxes that apply. Areas to be assessed include the following: • LOC • Orientation • Memory • Speech • Psychomotor • Mood • Behavior(s) including symptoms of abuse/neglect • Thought Content • Thought Process • Appearance • Self-Harm Assessment • Aggression to Others/Property • Seclusion/Restraint Prevention Positive findings: The registered nurse describes and triggers to the MPA positive findings in the areas of current danger to self or others and alterations in thought. Printed 01/30/15 3-7
  8. 8. Patient Assessment upon Admission UTHCPC Policies and Procedures Patient Care – Treatment Services Continued on next page 3-8 Printed 01/30/15
  9. 9. UTHCPC Policies and Procedures Patient Assessment upon Admission Patient Care – Treatment Services Nursing Admission Assessment, Continued Nutrition screen, assessment and evaluation The registered nurse: • Assesses the patient’s current level of nutritional status by eliciting information on the following: – Usual body weight, Ht., Wt. – Diet prior to admission – Appetite prior to admission • Checks for any items that require a nutrition consult • If no items are checked, a nutrition consult is not indicated • If one or more conditions are selected, sends notification to the registered dietician via the computer under "Nutrition Consult" – Indicates a trigger to the MPA The registered dietitian: Completes the nutrition assessment and evaluation Patient/family education The registered nurse identifies learning need(s) and educates patients/family as appropriate. Education includes instruction in the specific health topic and/or skill the patient/family needs to meet the patient’s ongoing health care needs. Initial nursing plan of care The registered nurse identifies, summarizes, prioritizes and documents the patient's immediate care needs and interventions after completing the Initial Nursing Assessment. Signature Following completion of the Nursing Initial Admission Assessment/Data, the registered nurse provides a signature noting licensure, and dates and times of completion. Forms Nursing Initial Admission Assessment/Data Nursing Intake/Reassessment Form Child and Adolescent Addendum Printed 01/30/15 3-9
  10. 10. Patient Assessment upon Admission UTHCPC Policies and Procedures Patient Care – Treatment Services Psychosocial Assessment Introduction to Psychosocial Assessment Date of Last Review 02/12/04 SME: Suzanne Foster A Social Services Clinician (SSC) makes an assessment of the patient’s current psychosocial functioning and of the patient’s significant social resources/stressors. The assessment includes a review of the patient’s psychosocial development and history. It concludes with the patient’s tentative discharge plan. Purpose The patient’s current functioning and resources/stressors and psychosocial and developmental histories are explored for the following purposes: • To assess his/her achievement of, or failure to achieve, significant developmental milestones from birth to the present. • To evaluate the impact of the family of origin and any nuclear families on the patient’s development and functioning • To assist in the elaboration of a treatment and discharge plan that will promote the patient’s maximum independent functioning Timeframe The assessment is completed as soon as possible but at least within 72 hours of the patient’s admission. Pertinent information is added to the assessment as it becomes available in the course of the patient’s stay. • If the patient refuses to be interviewed or is unable to be interviewed because of the symptoms of mental illness, an attempt must be documented on the Interdisciplinary Initial Assessment Cover sheet within 72 hours and every 48 hours thereafter until the assessment is completed or the patient is discharged. • When possible and permitted, the SSC contacts significant others who can provide information to complete the assessment. MPA The SSC summarizes on the Multidisciplinary Problem Aggregate (MPA) any psychosocial problems that may have an impact on the patient’s development and functioning in the present and on the treatment and discharge planning. Continued on next page 3-10 Printed 01/30/15
  11. 11. UTHCPC Policies and Procedures Patient Assessment upon Admission Patient Care – Treatment Services Psychosocial Assessment, Continued Readmission When a patient is readmitted to UTHCPC and a complete Psychosocial Assessment had been completed during a previous admission, the SSC does the following: • Reviews the previous assessment with the patient/family for completeness and accuracy and edits the document accordingly. Edits are placed in brackets with the date and initials of the clinician.” • Reflects the current admission in the Presenting Problems • Develops a new Tentative Discharge Plan for the current admission • Copies the electronic report, signs and dates the report, and places it in the current record Form elements The following are the elements of the Psychosocial Assessment form: • Informant • Problems/Stressors – Admission criteria – Other problems impacting treatment and discharge planning • Developmental and Medical History • Psychiatric History • History of, or presently suicidal/homicidal ideation/gesture • Substance Use and Treatment History • Abuse History • Legal History • Family of Origin History • Nuclear Family History • Current Resources – Spiritual/Religious/Cultural Resources – Hobbies/Recreational Activities – Employment Status – Financial Resources – Insurance Resources – Citizenship Status – Living Arrangements • Preliminary Discharge Plan • Social Service Clinician signature/credentials; signature/credentials of an LMSW if SSC from another discipline/license; originator name on revised document Continued on next page Printed 01/30/15 3-11
  12. 12. Patient Assessment upon Admission UTHCPC Policies and Procedures Patient Care – Treatment Services Psychosocial Assessment, Continued Process This table describes how the SSC completes the Psychosocial Assessment Stage Description 1 Reviews the following: • Referral information, including Harris Co. Psychiatric Intervention/Probate Court documents and reports from transferring institutions • Assessments made by other disciplines: the Initial Psychiatric Evaluation, the Nursing Assessment, and Music and Recreational Therapy Assessments. • Any previous psychosocial assessment 2 Interviews the following to obtain sufficient information to complete or update the assessment: • Patient • Parent of a minor • Guardian • And/or applicant (informant) for court-ordered mental health treatment • And/or family/significant others (if patient has consented to their involvement) 3 Explains to the patient the confidentiality of the information as well as the limits of confidentiality. Informs involuntarily-admitted patient that the content and process of the interview will be made available to the Probate Court for its decision-making process. 4 Obtains written consent from the patient to involve others in the assessment, treatment, and discharge processes. 5 Enters the information obtained on the Psychosocial Assessment Flow sheet in the Sunrise Clinical Manager electronic record. Checks the appropriate options listed within each subheading and adds explanatory comments wherever possible. 6 Prints a copy of the document. Signs and dates the document when completed and files in the medical record. 7 Notes all significant psychosocial problems on the Multidisciplinary Problem Aggregate. Lists strengths on the Integrated Summary. Forms Multidisciplinary Problem Aggregate Related standards JCAHO PE 1-1.1, PE 1.6, PE 3.1, PE 4-4.2 Continued on next page 3-12 Printed 01/30/15
  13. 13. UTHCPC Policies and Procedures Patient Assessment upon Admission Patient Care – Treatment Services Psychosocial Assessment, Continued Forms Psychosocial Assessment Multidisciplinary Problem Aggregate Related standards JCAHO PE 1-1.1, PE 1.6, PE 3.1, PE 4-4.2 Printed 01/30/15 3-13
  14. 14. Abuse and/or Neglect Assessment UTHCPC Policies and Procedures Patient Care – Treatment Services Patient and Family Education Assessment Introduction Date of Last Review 02/12/04 SME: Dorothy Matthews UTHCPC provides patient/family education to enhance the patient/family knowledge, skills, and behaviors s/he needs to restore quality of life and make informed health care decisions. Assessment Education for patients/family must be based on assessment of their: • Ability to learn based on the following: – Cultural and religious practices – Emotional barriers – Desire and motivation to learn – Physical and/or cognitive limitations – Language barriers • Learning needs including the above factors and skills/knowledge deficits Education topics Education include instruction in the specific knowledge and/or skills the patient/family needs to meet the patient's ongoing health care needs, including but not limited to the following: • Current health status • Safe and effective use of medication, if any • Safe and effective use of medical equipment, if any • Instruction on potential drug-food interactions and counseling on nutrition intervention and/or modified diets, as appropriate • Instruction in rehabilitation techniques to facilitate adaptation to and/or functional independence in the environment, if needed • Access to available community resources, if needed • When and how to obtain further treatment, if needed Continued on next page 3-14 Printed 01/30/15
  15. 15. UTHCPC Policies and Procedures Abuse and/or Neglect Assessment Patient Care – Treatment Services Patient and Family Education Assessment, Continued Importance of education Patient and family education is important because it helps patient/family as follows: • Facilitates the patient/family understanding of the patient's health status and health care options selected • Increases patient/family potential to follow the therapeutic health care plan • Maximizes care skills • Increases patient/family ability to cope with the patient's health status/prognosis/outcome • Enhances the patient/family role in continuing care and promoting a healthy lifestyle • Teaches the patient/family skills and techniques to aid in improved outpatient functioning • Encourages participation in decision-making about health care options Educational resources Educational resources is selected and provided based on patient/family needs and include but not be restricted to the following: • One-to-one presentations • Group classes • Video tapes • Pamphlets and patient handouts • Information on community resource availability and access • UTHCPC television Channel 7 (internal programming) Discharge instructions The individual or organization responsible for the continuing care of the patient receives information about any discharge instructions. Individualized education The treatment team adapts the education to the appropriate age, culture, and language and individualizes it for the specific patient/family. The patient and family educational process will be interdisciplinary, as appropriate to the plan of care. Medical record inclusion The treatment team documents the education of the patient/family in the patient's medical record or the Patient/Family Education Sheet. Such documentation must include the following: • Assessment and identification of educational needs • The interventions the staff member used to meet those needs • The patient/family understanding of the instruction or education Continued on next page Printed 01/30/15 3-15
  16. 16. Abuse and/or Neglect Assessment UTHCPC Policies and Procedures Patient Care – Treatment Services Patient and Family Education Assessment, Continued Education sheet Documentation on the education sheet begins within twenty-four hours of the patient’s admission. Any additional education that the treatment team documents on the Patient/Family Education Sheet must be as follows: • Related to the patient’s problem(s) as identified on the Master Treatment Plan • Must have a lesson plan included in the Patient and Family Education manual Other documents All other education will be documented in the progress notes. Form Patient/Family Education Sheet Related standards JCAHO PF 1-4.2 3-16 Printed 01/30/15
  17. 17. UTHCPC Policies and Procedures Abuse and/or Neglect Assessment Patient Care – Treatment Services Admission History and Physical – Initial Psychiatric Examination When completed Date of Last Review 02/12/04 Dr. Roy Varner All patients receive a history and physical examination within 24 hours after admission. The multi-page form for this initial assessment is the Initial Psychiatric Examination (IPE). On-call residents may use the Brief Initial Psychiatric Examination (BIPE) form when the IPE can be deferred. Note: If a pertinent history and physical has been performed within 30 days prior to admission, by a medical staff member of a JCAHO accredited healthcare organization, then a durable, legible copy of such history and physical may be placed in the patient’s medical record in lieu of the admission history and physical. The copy must be signed and dated, and may be used provided that a record has been made of all additions to the history, and any changes in physical/mental findings in the form of an interim summary progress note. Re-attempts to assess If the patient refuses to be examined or is unable to be completely examined because of the symptoms of mental illness, an attempt must be documented on the Interdisciplinary Initial Assessment Cover Sheet within 24 hours and every 24 hours thereafter until the assessment is completed. Physician responsibility If a resident physician (rather than an attending physician) completes the initial assessment (IPE), the attending physician who has also examined the patient within the same time frame verifies it. Verification: The attending physician verifies the examination by doing the following: • Documenting his/her corrections (as indicated) • Co-signing the document • Writing an attending admission note referencing the IPE (and admitting orders) verifying the following: – Acknowledging the resident’s note by the name of the resident – Key historical elements of the patient’s present illness – Mental and physical state – Diagnoses – Medical decision making Continued on next page Printed 01/30/15 3-17
  18. 18. Abuse and/or Neglect Assessment UTHCPC Policies and Procedures Patient Care – Treatment Services Admission History and Physical – Initial Psychiatric Examination, Continued Form elements The following are the elements of the Initial Psychiatric Examination form: • Presenting problem/justification for admission including chief complaint • Past Family and Social History (PFSH) • Review of systems • Mental status examination • Physical examination • Admitting diagnoses and differential diagnosis • Assets • Problem areas • Actions • Signatures Presenting problem/ justification for admission The physician summarizes the course of the presenting problem(s)/justification for admission, including the following: • Onset and other time invervals • Interventions • Reactions of others involved Section framing: This section should be framed in 4 or more of the following dimensions: • Location • Quality • Severity • Duration • Timing • Context • Modifying factors • Associated symptoms Chief complaint The physician provides a concise statement of the reason for the hospitalization. The statement should include one or two sentences from the patient, and/or significant others, as to reasons given for the patient needing admission using their own words if possible. Continued on next page 3-18 Printed 01/30/15
  19. 19. UTHCPC Policies and Procedures Abuse and/or Neglect Assessment Patient Care – Treatment Services Admission History and Physical – Initial Psychiatric Examination, Continued Past Family Social History The physician summarizes the following for past psychiatric, medical, family, and social history. Each area must be addressed: • Any past psychiatric history that appears to have immediate relevance to the current clinical episode Example: History of affective disorder, schizophrenia, or other recurring psychiatric disorders. • Any major medical problems that have impacted or are currently impacting on the patient’s condition • Any treatment that must be maintained for any current condition (current medications, dietary supplements, allergies) • Any history of past medical problems that may need immediate attention Example: Diabetes, asthma, cardiac problems, especially head trauma and substance abuse • Relevant family and social history Review of systems The physician completes a pre-determined checklist, part of the IPE, which complements findings in the physical examination, mental status examination, and/or the admissions nursing assessment parts I-IV. Mental status examination The physician writes a brief assessment including the following in sufficient detail for measuring change at discharge: • General appearance/behavior • Gait, muscle tone, abnormal movements • Speech • Thought processes • Thought content • Perception • Mood/affect • Insight/judgment • Cognitive exam (orientation, attention/concentration, knowledge, abstractions, memory) • Estimated intelligence (high?, average?, low?, retarded?) Continued on next page Printed 01/30/15 3-19
  20. 20. Abuse and/or Neglect Assessment UTHCPC Policies and Procedures Patient Care – Treatment Services Admission History and Physical – Initial Psychiatric Examination, Continued Physical examination The physician notes having reviewed vital signs, assessing for evidence of abuse and documents findings of the physical examination. The physician notes whether the primary examination was performed by a medical student or by the physician. Items to examine during the physical examination are listed below: Item Description 1 General Appearance 2 Skin 3 Lymphatics 4 HEENT/Neck 5 Chest/Lungs 6 Cardiovascular 7 Abdomen 8 Genitalia and Rectal, Pelvic, When completed: These examinations should be completed or referred later when indicated as determined by a body region specific review of systems. 9 Back/Extremities 10 Neurologic Exam as follows: • Cranial Nerves (state if intact and check how tested) − I. (by identification of a known substance) − II. (by distinguishing movements in the peripheral visual fields) − III, IV, VI. (by demonstrating extraocular muscle movements) − V. (by distinguishing sensation throughout the trigeminal nerve distribution) − VII. (by demonstrated facial muscles of expression) − VIII. (by demonstrating bilateral hearing) − IX. (by demonstrating a gag reflex) − X. (by phonating guttural sounds) − XI. (by demonstrating a bilaterally symmetrical shoulder shrug) − XII. (by protruding the tongue without fasciculation) • Motor (include strength, involuntary movements) • Sensory • Reflexes • Gait/Romberg • Head circumference (child/adolescent only) Continued on next page 3-20 Printed 01/30/15
  21. 21. UTHCPC Policies and Procedures Abuse and/or Neglect Assessment Patient Care – Treatment Services Admission History and Physical – Initial Psychiatric Examination, Continued Admitting diagnoses The physician completes the admission psychiatric diagnoses as follows: • List all applicable DSM-IV TR Plus Axis I diagnoses • List all applicable DSM-IV TR Plus Axis II diagnoses if known at the time • List all applicable DSM-IV TR Plus Axis III diagnoses. Include any major or significant medical (physical) problems for which the patient is currently under treatment, as described in the admission process and documents, or write “No Diagnosis” • List all applicable DSM-IV TR Plus Axis IV psychosocial and environmental problems • List the DSM-IV TR Plus Axis V (GAF) Differential diagnosis The physician documents a differential diagnosis. Assets The physician lists the patient's assets in descriptive, not interpretive fashion, that can be used in the institution of treatment and development of the master treatment plan. Example: Knowledge, interests, skills, aptitudes, experience, education, employment status, insight, cooperativeness. Relevant items: The physician should move relevant items to the Multidisciplinary Problem Aggregate (MPA). Problem Areas The physician lists problems (symptoms), both physical and psychiatric, which form the psychiatrist’s input to the Master Treatment Plan (MTP). Actions The physician checks the appropriate boxes regarding actions undertaken. Signature Admitting resident: The admitting resident signs his/her legal name, as it appears in hospital records, and degree initials, then writes the date. The admitting resident also prints his/her last name in the space provided. Admitting Attending: The admitting attending physician reviews and co-signs the Admission History and Physical and Psychiatric Evaluation form, using legal name and degree initials, then dates. Forms Brief Initial Psychiatric Examination (BIPE) Initial Psychiatric Examination (IPE) MPA, Integrated Summary, and MTP Continued on next page Printed 01/30/15 3-21
  22. 22. Abuse and/or Neglect Assessment UTHCPC Policies and Procedures Patient Care – Treatment Services Admission History and Physical – Initial Psychiatric Examination, Continued Related Standards JCAHO PE 1, PE 1.5-1.6.1.1, PE 1.8, PE 4-4.3, PE 5 JCAHO MS 6.2, MS 6.2.2.1 Physician’s Current Procedural Terminology, copyright American Medical Association, all rights reserved 1995 Documentation Guidelines for Evaluation and Management Services Evaluation and Management Guidelines 3-22 Printed 01/30/15
  23. 23. UTHCPC Policies and Procedures Abuse and/or Neglect Assessment Patient Care – Treatment Services Pain Management Introduction Date of Last Review 02/12/04 SME: Arslee Mackey The assessment of pain and its management is multidisciplinary in nature and is shared among all physicians, nursing staff, and other clinicians. Pain management is monitored through Performance Improvement. Policy This procedure is based on the hospital’s Pain Management Plan which supports our mission of patient care. The plan acknowledges that patients have a right to have their pain assessed and managed through techniques that respect their dignity, autonomy, positive self-regard, civil rights, and involvement in their own care. Education Staff receive pain management education during New Employee Orientation and annually thereafter. Both pain assessment and management are included in nursing staff competencies. Pain assessment The pain assessment process is as follows: Step Action 1 The physician assesses for pain during the Initial Psychiatric Examination (IPE). 2 Additionally, nursing staff screen for pain in the Initial Nursing Assessment. 3 When a patient has a positive pain history, as identified in the nursing assessment, the following information is obtained from the patient: • Severity of pain (pain score) • Character, frequency, location, duration • What makes the pain better • What makes the pain worse • Methods used to successfully control pain • What staff can to do help manage the pain 4 When pain is identified upon admission or during the hospital stay, nursing staff reassess ongoingly as follows: • The pain rating is entered on the graphic sheet • As applicable, the pain rating is entered on the PRN Medication Sheet 5 As appropriate, pain management may become part of the Master Treatment Plan. Continued on next page Printed 01/30/15 3-23
  24. 24. Abuse and/or Neglect Assessment UTHCPC Policies and Procedures Patient Care – Treatment Services Pain Management, Continued Pain assessment (continued) The pain assessment process is as follows (continued): Step Action 6 Nursing staff apprise the attending physician of patients experiencing pain. Pain Management Guidelines/Modalities are implemented per physician’s order. 7 Nursing staff assess/reassess pain and interventions to alleviate pain and document in the medical record. Note: Ineffective pain management is discussed with the treatment team and the treatment plan and/or physician orders are revised as appropriate. 8 During the admission process, nursing staff educate the patient on her/his rights to pain management and the right to self-report pain. Documentation: Pain education is documented on the Patient/Family Education Sheet. 9 The patient/family receive ongoing education (i.e. pamphlets, groups, referrals, etc.) as appropriate. Documentation: Pain education is documented on Patient/Family Education Sheet and/or in the progress notes. Related standard JCAHO PE 1.4 3-24 Printed 01/30/15
  25. 25. UTHCPC Policies and Procedures Abuse and/or Neglect Assessment Patient Care – Treatment Services Master Treatment Planning/Review Process Introduction Date of Last Review 02/12/04 SME: Arslee Mackey UTHCPC adopted the Master Treatment Plan (MTP) to ensure that each patient has a comprehensive, age-specific, individualized plan for treatment that addresses his/her biological, psychological, educational, social, cultural, and developmental needs and choices. Cover sheet The physician enters the Axis I diagnosis on the cover sheet. The attending physician, representatives of all disciplines participating in the patient's initial treatment planning session, and the patient/guardian/parent of minor <16 signs the Master Treatment Plan Cover Sheet. (If the patient is unable to review the cover sheet during multidisciplinary rounds, the RN follows up with the patient.) MPA The Multidisciplinary Problem Aggregate (MPA) as well as the Initial Psychiatric Examination (IPE) contains a listing of critical problems gathered from the discipline-specific assessments as follows: • The responsible disciplines, Nursing, Social Services staff, enter the problems/triggers on the Multidisciplinary Problem Aggregate (MPA) within 24- 72 hours of admission. • Entries to the MPA are documented in problem terms – the responsible disciplines check entries that correspond to the assessment document. • MPA entries may contain some historical data. Patient assets/stressors The plan of care and treatment is based on the patient’s assets and stressors as identified in the assessment. The disciplines (Nursing/Social Services staff) check ( ) asset(s)/stressors as appropriate. Integrated Summary/Problem List (IS/PL) The integrated summary/problem list reflects an individual’s psychiatric and physical needs. The physician, in collaboration with other disciplines, evaluates and aggregates information captured on the MPA to formulate clinical impressions through the creation of a problem list. • The IS/PL is intended to consolidate the clinical information gathered from the discipline assessments/MPA into a single evaluation. Check ( ) and date appropriate problem(s) based on the analysis of consolidated clinical information. • The integrated summary/problem list is prioritized by the physician using the following codes (*, N, X, O). Continued on next page Printed 01/30/15 3-25
  26. 26. Abuse and/or Neglect Assessment UTHCPC Policies and Procedures Patient Care – Treatment Services Master Treatment Planning/Review Process, Continued MTP The Master Treatment Plan (MTP) is a document that identifies problem(s), goals/objectives, interventions and discharge criteria. The MTP is completed within 3 days of admission. The following is the process of master treatment planning: Step Process Action 1 Integrated Summary/ Problem List After problem(s) have been identified and prioritized on the IS/PL, the attending physician and other members of the treatment team establish the MTP. 2 MTP Problem Page(s) Staff pulls the appropriate MTP Problem(s) page which corresponds to the problems checked ( ) on the IS/PL. If a problem is identified that does not have a corresponding MTP Problem page, the discipline adds a blank MTP Problem page to be completed by appropriate disciplines. 3 Goal(s) Goals for each problem are stated in measurable behavioral terms (i.e. eliminate, diminish, etc.) The individual disciplines check ( ) the box corresponding to the goal(s) that the individual patient should achieve. Disciplines add additional goal(s) as required based on patient needs. 4 Discharge Criterion Goals designated as discharge criteria are considered short- term goals which are accomplished during the hospital stay. These goals guide staff in knowing when the individual is ready for discharge. The attending physician marks goals that are discharge criteria by placing a ( ) in the “discharge criterion” column. 5 Intervention • Interventions are planned actions designed by staff to meet behavioral changes identified as goals. Interventions include the frequency and the discipline responsible for carrying out the intervention(s). • The individual discipline(s) check ( ) the box corresponding to the appropriate intervention. Disciplines add additional intervention(s) as required based on patient needs. 6 Responsible Discipline Multiple disciplines may be responsible for an intervention. The disciplines(s) responsible for execution of the intervention circle their discipline in the “responsible discipline(s)” column. Continued on next page 3-26 Printed 01/30/15
  27. 27. UTHCPC Policies and Procedures Abuse and/or Neglect Assessment Patient Care – Treatment Services Master Treatment Planning/Review Process, Continued MTP Review Master Treatment Plan reviews are conducted no longer than 7 days after initiation of the plan as reflected on the MTP Review form. The treatment plan review process examines the patient’s progress in relation to goal attainment and timeframes. Additions, deletions, or revisions of goals and interventions may be warranted. The patient/family participates in the process as appropriate. Forms Initial Psychiatric Examination Interdisciplinary Patient Assessment MPA, Integrated Summary, and MTP Related standards JCAHO CC 2.1 JCAHO MS 6.1, MS 6.6-6.6.1 JCAHO RI 1.2 Printed 01/30/15 3-27
  28. 28. Abuse and/or Neglect Assessment UTHCPC Policies and Procedures Patient Care – Treatment Services Abuse and/or Neglect Assessment Responsibilities TXMHMR definitions Date of Last Review 02/12/04 SME: Greg Gigax UTHCPC defines abuse, neglect, and exploitation by adopting the TXMHMR definitions set out in the Texas Administrative Code, 40 TAC 710 and 25 TAC 404. The State of Texas has three statutes that establish the criteria for identifying and reporting abuse or neglect as follows: • Chapter 161, Subchapter L of the Texas Health and Safety Code “Abuse, Neglect and Unprofessional Conduct in Health Care Facilities” • Chapter 34 of the Texas Family Code “Report of Child Abuse” • Chapter 48 of the Texas Human Resource Code, “Protective Services for the Elderly” Employee responsibility UTHCPC employees are required to assess and report suspected and alleged cases of abuse and neglect to the appropriate authorities, see Reporting Suspected Abuse/Neglect/Exploitation. Note: For reporting suspected abuse, neglect or exploitation occurring at UTHCPC, consult the procedure on Reporting and Investigating Abuse/Neglect/Exploitation at UTHCPC. Staff Training UTHCPC staff are required to complete 8 hours of Patient Rights training on initiation of employment and every year thereafter. These 8 hours of training include the following: • Assessment criteria for victims • Reporting guidelines • Identification of private and public community agencies that provide help and assistance for victims Clinical staff assessment Assessment for abuse and neglect is an ongoing process from admission through discharge. Each of the following clinical staff must note on his/her respective assessment tools that s/he has completed an evaluation for identification of abuse and/or neglect at time of admission to the facility: • Registered nurse • Social service clinician • Physician Positive findings If a clinical staff finds positive findings of suspected or alleged abuse/neglect, s/he must do the following: • Triggers the findings to the MPA for consideration on the Master Treatment Plan • Follows the reporting guidelines indicated above Continued on next page 3-28 Printed 01/30/15
  29. 29. UTHCPC Policies and Procedures Abuse and/or Neglect Assessment Patient Care – Treatment Services Abuse and/or Neglect Assessment Responsibilities, Continued Registered nurse responsibilities The registered nurse interviews the patient privately to conduct an abuse/neglect assessment of the patient’s behavioral and physical findings at present to note criteria that may be suggestive of abuse and/or neglect. Does the clinician indicate that findings match criteria of abuse? • If yes, the registered nurse completes the direct questioning and triggers a problem statement to the MPA. • If no, the registered nurse does not observe the criteria. Social services responsibilities The social service clinician assesses the patient further within the context of the Psychosocial Assessment to determine the following: • The actual history of the suspected abuse/neglect • The family history and onset Physician responsibilities The physician assesses further the physical and mental condition of the patient to determine whether the patient can have proper care at UTHCPC or should be transferred to a medical facility (BTGH). Considering abuse: The physician considers the possibility of abuse/neglect and follows it with history and physical examination in the following situations: • When the patient’s explanation of how s/he had an injury does not seem plausible • When a delay in seeking medical care exists • When the patient presents with vague complaints Reporting abuse or neglect Health professionals are obligated to report suspicions of abuse or neglect of adults or children to the Texas Department of Protective and Regulatory Services at 1-800-252-5400. Continued on next page Printed 01/30/15 3-29
  30. 30. Abuse and/or Neglect Assessment UTHCPC Policies and Procedures Patient Care – Treatment Services Abuse and/or Neglect Assessment Responsibilities, Continued Referral resources If a patient is identified as a victim of abuse/neglect, the treatment team refers him/her to available resources. UTHCPC maintains the following list of national, state and local resources: Where Who Phone number National National Domestic Violence Hotline 1-800-799-7233 National Center on Elder Abuse (Eldercare locator) 1-800-677-1116 National Resource Center on Domestic Violence 1-800-537-2238 National Council on Child Abuse & Family Violence 1-202-429-6695 State/local UTHCPC Patient Relations 713-741-7859 24-Hour Abuse Hotline, reporting, referrals, shelters, funding 1-800-252-5400 Women’s Center Hotline 713-528-2121 Crisis Hotline 713-228-1505 Bay Area Women’s Center 281-422-2292 Sexual Assault Hotline 713-528-7273 Crisis services Crisis Intervention of Houston 713-228-1505 Spanish Hotline 713-526-8088 National Domestic Violence Hotline 1-800-799-7233 Coun- seling services Aid to Victims of Domestic Abuse Pivot Project (Intervention/Prevention Service for men who are violent) 713-522-5161 713-524-4357 Asian American Family Counseling Center 713-339-3688 Baylor Psychiatric Clinic 6655 Travis 77030 713-798-4856 Catholic Charities, Associated 713-526-4611 Continued on next page 3-30 Printed 01/30/15
  31. 31. UTHCPC Policies and Procedures Abuse and/or Neglect Assessment Patient Care – Treatment Services Abuse and/or Neglect Assessment Responsibilities, Continued Referral resources (continued) If a patient is identified as a victim of abuse/neglect, the treatment team refers him/her to available resources. UTHCPC maintains the following list of national, state and local resources (continued): Where Who Phone number Coun- seling services Center for Counseling 281-530-6203 Center for Creative Resources 713-461-7599 Chicano Family Center 713-923-2316 Northwest Assistance Ministries: Family Violence (for Women) 281-885-4673 Family Outreach Center 713-748-7409 Family Service Center 713-861-4849 Gay and Lesbian Switchboard of Houston 713-529-3211 Houston Area Women’s Center 713-528-2121 Interface-Samaritan Counseling Center 713-626-7990 Jewish Family Service 713-667-9336 Montrose Counseling Center 713-529-0037 University of Houston – Clear Lake 281-283-3330 University of Houston Psychological Research & Service Center 713-743-8600 University of Texas – Mental Sciences Institute 713-500-2500 Veteran’s Affairs Medical Center: Peace Clinic 713-794-7101 Continued on next page Printed 01/30/15 3-31
  32. 32. Abuse and/or Neglect Assessment UTHCPC Policies and Procedures Patient Care – Treatment Services Abuse and/or Neglect Assessment Responsibilities, Continued Referral resources (continued) If a patient is identified as a victim of abuse/neglect, the treatment team refers him/her to available resources. UTHCPC maintains the following list of national, state and local resources (continued): Where Who Phone number Shelters for battered women Bay Area: Bay Area Women’s Center Turning Point (Hotline: 281-286-2525) Baytown Area Women’s Center 281-422-2292 281-338-7600 1-800-824-4807 Brazoria County 24 hour # 1-800-243-5788 Houston: Casa Juan Diego 4818 Rose, 77077 Footsteps in the Sand (also children) (off 59, NE of downtown) Houston Area Women’s Ctr. 1010 Waugh Just A Step Away House 4828 Loop Central #100, 77081 Wellsprings 713-869-7376 713-631-3369 713-528-2121 713-662-9981 713-529-6559 Ft. Bend Co. Women’s Center 1002 Wilson, Rosenberg, TX 77471 281-342-4357 Galveston Crisis Center 1-409-765-7233 Humble: The Door, 101 Main/Humble, TX 281-446-2615 Montgomery County Woman’s Center, 903-A Hilcrest Dr./Conroe 936-441-2085 Pasadena: The Bridge Over Troubled Waters, 1001 E. Southmore #200 713-473-2801 Related standards JCAHO PE.1, 1.6, 3, 4, 4.3, 6 3-32 Printed 01/30/15
  33. 33. UTHCPC Policies and Procedures Abuse and/or Neglect Assessment Patient Care – Treatment Services Abuse and/or Neglect Assessment Criteria Criteria Date of Last Review 02/12/04 SME: Greg Gigax The assessment criteria do not provide all possible signs of abuse or neglect that may present to the clinician during the assessment process. The criteria are focused on observable evidence and not allegations alone. Physical examination/ criteria Combinations of the criteria along with direct reporting and physical examination provide the data the clinician needs for him/her to take the appropriate action as UTHCPC policies regarding abuse and neglect direct. Identifying abuse Physical and behavioral criteria are used to identify the following abuses: • Physical • Rape/sexual • Emotional • Domestic Abuse Definitions: See procedure on Abuse/Neglect/Exploitation Definitions Reporting: See procedure on Reporting Suspected Abuse/Neglect/Exploitation Physical findings The physical findings criteria are as follows: Kind Description Burns • Cigar or cigarette burns, especially on the soles, palms, lips, cheeks, back, buttocks • Immersion burns (stocking or glove-like without splash burns on extremities, doughnut-shaped on buttocks or genitals) • Patterned burns resembling an electrical appliance especially when on a non-exploratory body surface • Rope burns, particularly on wrist, ankles, neck, torso Continued on next page Printed 01/30/15 3-33
  34. 34. Abuse and/or Neglect Assessment UTHCPC Policies and Procedures Patient Care – Treatment Services Abuse and/or Neglect Assessment Criteria, Continued Physical findings (continued) The physical findings criteria are as follows (continued): Kind Description Injuries • Injuries to the head, neck, chest, breasts, abdomen, and genitals • Unusual injury marks that resemble the shape of the article used to inflict injury Example: Belt, rope, hairbrush, hand, teeth, electrical cord • Numerous injuries at multiple sites (outside of motor vehicle accident or other catastrophe), especially those injuries appearing to be in various stages of healing • Injuries that have not been cared for properly or at all • Injury that is inconsistent with explanation for its cause Bone fracture Skull, ribs, long bone fractures Infection • Infections in children not commonly occurring, Example: Venereal warts, syphillis, gonorrhea or chlamydia • Gynecologic problems, frequent vaginal and urinary tract infections, pelvic pain Pain • Pain from touching • Chronic pain, psychogenic pain, or pain due to diffuse trauma without visible evidence Physical symptoms Physical symptoms related to stress Example: Sleep and appetite disturbances, chronic headaches, abdominal and GI complaints, atypical chest pain Other • Bruises and welts forming regular geometric or symmetrical patterns • Lacerations or abrasions to palate, mouth, gums, lips, eyes, ears, external genitalia (ex: vaginal or rectal tears) Continued on next page 3-34 Printed 01/30/15
  35. 35. UTHCPC Policies and Procedures Abuse and/or Neglect Assessment Patient Care – Treatment Services Abuse and/or Neglect Assessment Criteria, Continued Behavior/mental health criteria The behavioral and mental health criteria are as follows: If the person is the… Behaviors may be described by… Parent/guardian/ partner • Process of emotional abuse is observable Example: Partner/parent/guardian yells, threatens, swears • Partner/parent/guardian accompanies patient, insists on staying close, and answers all questions directed to the patient • Denial or minimization of violence by either partner/parent/guardian or patient • Partner/parent/guardian’s lack of affection towards patient or withholds affection when showing affection would be appropriate. Patient • Feelings of isolation and inability to cope • Suicide attempts or gestures • Contradictory statements, implausible stories, conflicting accounts of incidents • Reluctance of a patient to speak or disagree in front of partner/parent/guardian • Patient’s exaggerated sense of personal responsibility for the relationship, including self-blame for partner/parent/guardian’s abuse/neglect • Fearful of caregivers • Depression • Alcohol or drug abuse • Panic attacks and other anxiety symptoms • Vague, nonspecific complaint of ill or failing health • Verbal expressions of “I can’t seem to do anything right” or “I can’t seem to do what I’m supposed to do” • History of promiscuous behavior • Draws away from socially appropriate contact • Bedwetting, encopresis Related standards JCAHO PE.1, 1.6, 3, 4, 4.3, 6 Printed 01/30/15 3-35
  36. 36. Therapy Assessment/Services UTHCPC Policies and Procedure Patient Care – Treatment Services Therapeutic Recreation Assessment When determined Date of Last Review 02/12/04 SME: Joanie Amason-Norland The admitting physician orders the Social Service Clinician to assess the patient and involve in group therapy per criteria as appropriate. Following the completion of the Master Treatment Plan, the Clinician completes the Group Schedule. This form is designed to assign the patient to groups according to group criteria and patient issues. Treatment needs Therapeutic Recreation services are coordinated through the Social Service department. To provide individualized treatment, patients are asked to complete a Therapeutic Recreation Assessment. The assessment tool may be completed by the patient or through the Recreation Therapist’s interview of the patient. Result: Upon completion of the assessment, the Recreation Therapist identifies treatment needs according to the problems identified by the treatment team. Assessment completion The assessment tool must be completed within 72 hours of receipt of the therapeutic recreation order. The therapist then enters the assessment information into the Sunrise Clinical Manager system. Incomplete Assessment: If unable to complete the assessment within the 72-hour timeframe, the therapist documents in the Progress Notes section of the patient’s chart the reason for non-completion. The progress note must indicate when a reattempt at assessment will be made. Continued on next page 3-36 Printed 01/30/15
  37. 37. UTHCPC Policies and Procedures Therapy Assessment/Services Patient Care – Treatment Services Therapeutic Recreation Assessment, Continued Assessment data entry The Recreation Therapist enters the data from the Therapeutic Recreation Assessment tool into the Sunrise Clinical Manager system as follows: In the Field… The Therapist… Date/time (at the top of the column) Enters date and time assessment was completed. POPULATION: Selects patient population: adult, child, or adolescent. PT COMPLETED EVAL?: Selects or free texts a description of the patient’s ability to complete the evaluation. PT ATTITUDE/RESPONSE TO EVAL: Selects or free texts patient’s level of participation and response to the evaluative process. AFFECT: Selects or free texts a description of the patient’s affect. MOOD: Selects or free texts a description of the patient’s mood. THOUGHT PROCESSES: Selects or free texts a description of the patient’s thought processes. MOTOR BEHAVIOR: Selects or free texts a description of the patient’s motor behavior. USE OF FREE TIME: Selects or free texts a description of how the patient utilizes free time. Continued on next page Printed 01/30/15 3-37
  38. 38. Therapy Assessment/Services UTHCPC Policies and Procedure Patient Care – Treatment Services Therapeutic Recreation Assessment, Continued Assessment data entry (continued) The Recreation Therapist enters the data from the Therapeutic Recreation Assessment tool into the Sunrise Clinical Manager system as follows: In the Field… The Therapist… PT. USE/EXPOSURE TO ETOH/DRUGS: Selects or free texts patient’s level of use/exposure to ETOH/drugs. DOES PATIENT EXERCISE? Selects or free texts patient’s level of exercise. DISPLAYS OF SADNESS INCLUDE: Selects or free texts a description of how patient displays sadness. DISPLAYS OF ANGER INCLUDE: Selects or free texts a description of how patient displays anger. LEISURE FUNCTIONS/BARRIERS: Selects or free texts patient’s level of leisure function and barriers for leisure involvement. PATIENT IDENTIFIED THE FOLLOWING PROBLEMS: Free texts a description of patient’s stated problems. GOALS TO BE ADDRESSED IN TR SESSION: Selects or free texts patient’s goals. PT ACTIVE IN GOAL SELECTION: Selects “yes” or “no” for patient’s participation in goal selection. RECREATION THERAPIST SUMMARY/COMMENTS: Free texts patient’s limitations, physical, cognitive, social, behavioral, emotional and level of involvement in leisure/play. Generating assessment form After data entry is complete the Therapist: • Prints the Therapeutic Recreation Assessment form • Signs and dates the form • Places the form in the patient’s chart under the assessment section Related standards JCAHO MS 6.5, PE 1, PE 1.7, PE 4-4.3 3-38 Printed 01/30/15
  39. 39. UTHCPC Policies and Procedures Therapy Assessment/Services Patient Care – Treatment Services Music Therapy Assessment When determined Date of Last Review 02/12/04 SME: Joanie Amason-Norlund The admitting physician orders the Social Service Clinician to assess the patient and involve in group therapy per criteria as appropriate. Following the completion of the Master Treatment Plan, the Clinician completes the Group Schedule. This form is designed to assign the patient to groups according to group criteria and patient issues. Treatment needs Music Therapy services are coordinated through the Social Service department. To provide individualized treatment, patients are asked to complete a Music Therapy Assessment. The assessment tool may be completed by the patient or through the Music Therapist interview of the patient. Result: Upon completion of the assessment, the Music Therapist identifies treatment needs according to the problems identified by the treatment team. Assessment completion The assessment tool must be completed within 72 hours of receipt of the music therapy order. The therapist then enters the assessment information into the Sunrise Clinical Manager system. Incomplete Assessment: If unable to complete the assessment within the 72-hour timeframe, the therapist documents in the Progress Notes section of the patient’s chart the reason for non-completion. The progress note must indicate when a reattempt at assessment will be made. Continued on next page Printed 01/30/15 3-39
  40. 40. Therapy Assessment/Services UTHCPC Policies and Procedure Patient Care – Treatment Services Music Therapy Assessment, Continued Assessment data entry The Music Therapist enters the data from the Music Therapy Assessment tool into the Sunrise Clinical Manager system as follows: In the Field… The Music Therapist… Date/time (at the top of the column) Enters date and time assessment was completed. PT COMPLETED EVAL?: Selects or free texts a description of the patient’s level of participation in the assessment process. PT ATTITUDE/RESPONSE TO EVAL: Selects or free texts a description of the patient’s overall attitude/response to the assessment process. AFFECT: Selects or free texts a description of the patient’s affect. MOOD: Selects or free texts a description of the patient’s mood. THOUGHT PROCESSES: Selects or free texts a description of the patient’s thought processes. MOTOR BEHAVIOR: Selects or free texts a description of the patient’s motor behavior. Continued on next page 3-40 Printed 01/30/15
  41. 41. UTHCPC Policies and Procedures Therapy Assessment/Services Patient Care – Treatment Services Music Therapy Assessment, Continued Assessment data entry (continued) The Music Therapist enters the data from the Music Therapy Assessment tool into the Sunrise Clinical Manager system as follows (continued): In the Field… The Music Therapist… MUSIC INVOLVEMENT: Selects or free texts a description gathered from “I enjoy each of the following.” CREATIVE EXPRESSION METHODS: Selects or free texts a description gathered from “How do you express your feelings?” MUSIC PREFERENCES: Selects or free texts a description gathered from “What kind of music do you enjoy?” MUSIC NOT PREFERRED: Selects or free texts a description gathered from “What kind of music do you dislike?” DISPLAYS OF SADNESS INCLUDE: Free texts information gathered from “When I feel sad, I show it by…” DISPLAYS OF ANGER INCLUDE: Free texts information gathered from “When I feel angry, I show it by…” ACTIVE IN GOAL SELECTION? Selects “yes” or “no”, or enters a free text description to indicate if the patient was able to identify which goals would be addressed in Music Therapy groups. MT GOALS: Selects or free texts a description gathered from “Place a check by any topics that you think could help you:” MUSIC THERAPIST SUMMARY/COMMENTS: Free texts a summary of the assessment using the D-Data, A-Assessment, P-Plan format. Generating assessment form After data entry is complete the Music Therapist: • Prints the Music Therapy Assessment form • Signs and dates the form • Places the form in the patient’s chart under the assessment section Related standards JCAHO MS 6.5, PE 1, PE 1.7, PE 4-4.3 Printed 01/30/15 3-41
  42. 42. Therapy Assessment/Services UTHCPC Policies and Procedure Patient Care – Treatment Services Interpretation Services Introduction Date of Last Review 09/10/04 SME: Suzanne Foster At UTHCPC, patients are entitled to communicate in a language that they understand. Purpose Interpretation services are available when a patient has limited English proficiency or has sensory impairment preventing communication with the treatment team. Interpreter An interpreter is a person who speaks languages other than English or a sign language. Available services The following interpretation services are available at UTHCPC: • AT&T Language Line • Language Competency Program Participants • International Translation Services • Sign Language AT&T Language Line Use for all languages except for Spanish and Vietnamese. Available 24 hours per day, all year. • Interpretation is provided only by telephone • The requester calls the AT&T language line direct at 1-800-532-1786 Language competency program A pair of units is assigned personnel that participate in the Language Competency Program. When an interpreter is needed, unit personnel or the department needing the service, contacts the staff that is assigned to cover the specific area. • Each team of interpreters is considered part of the area team and equally participates in supporting the assigned area, as the duties of their primary job permit • The team of interpreters will coordinate their planned absences to accommodate the support. If the circumstance warrants, an interpreter may and will be asked to interpret outside their assigned area. • On second shift there is one interpreter per designated area. An interpreter may on occasion have to be covered by an interpreter from another area. • If an interpreter is unavailable internally, then Language USA is contacted for an outside interpreter • On second, third shift, and weekends the Language Line will need to be utilized • Services for interpretation other than Spanish or Vietnamese will need to be accessed from an outside agency Continued on next page 3-42 Printed 01/30/15
  43. 43. UTHCPC Policies and Procedures Therapy Assessment/Services Patient Care – Treatment Services Interpretation Services, Continued Language Competency Program Participants Unit/ Spanish 1st Shift EXT. # 2nd Shift EXT. # 3rd Shift EXT. # 2B/2C Abraham Livingston (PT) Vickie Correa (PSM) 5045 7806 2D/2E Chris Morales (FM) Catalina DelaGarza (SS) 8695 3976 3B/3C Dan Gleeson (PT) Bertha Jeffrey (HIM) 4831 7888 1B/3E/Admit Delia Saenz (Admin) Patricia Gonzalez (COPES) 7870 3961 C/A Gonzalo Herrejon (FM) Ron Villaneda (FM) Melissa Garza-Benavides Ph.D. (PS) 8630 8690 3955 Reception/ Pt. Registration Sanjuana Lundy (Rec) Richard Martinez (PR) 8602 3883 Carmen Presiado (12:30-8:30) (Rec) 8601 Hospital Wide Martha Yavar (RN) Amanda Hernandez (RN) 4811 4830 Sergio Verduzco (PT) Patricia MacInerney (RN) 4826 4810 On Leave: Jairo Dunnard (PT) Norma Strength (PAS) Adm Administration FO Financial OperationMIS Management Information Systems FM Facilities Management HIM Health Information PT Psych Tech Management SS Social Services Language Line Services 1-800-523-1786 International Language Svc. 713-783-3800 Sign Shares, Inc. 713-869-4373 9/10/04 Continued on next page Printed 01/30/15 3-43
  44. 44. Therapy Assessment/Services UTHCPC Policies and Procedure Patient Care – Treatment Services Interpretation Services, Continued Language competency program participants Program participants are UTHCPC employees who are certified and hired to interpret. This service is for Spanish and Vietnamese speaking patients. • Interpretation is provided in person, or may be accomplished by telephone/conference call • If no one in your work area is a participant or fluent in the needed language, contact Social Services at 741-5985 between the hours of 8:00 a.m.-3:30 p.m. • If an interpreter is needed after 3:30 p.m., refer to the Interpreter’s Phone List to obtain assistance. International translation services This service provides an interpreter in person and may be requested by physician order. • Contact Social Services at 741-5985 between the hours of 8:00 a.m.-3:30 p.m. • If an interpreter is needed after 3:30 p.m. for a language other than Spanish or Vietnamese, contact the AT&T language line at 1-800-532-1786 Sign language This service uses the American Sign Language method. • Contact Social Services at 741-5985 between the hours of 8:00 a.m. and 3:30 p.m. • Provide the following information: – Name of patient – Amount of time interpreter is needed – What specific duty you need the interpreter to perform (example: discharge planning, family meeting) • If an interpreter is needed after 3:30 p.m., contact Sign Shares at 713-869-4373 • If an interpreter cannot be reached, use the American Sign Language reference books in room 2B44 (Nursing Supervisor’s office) and fill out the sign-out book • If the need is not immediate, you may leave a voice mail by contacting Social Services at 741-5985 Survey To maintain a quality and efficient service, Social Services requests that the users of the Language Competency Program complete the UTHCPC Translation Services Survey. Further information For further information, staff may contact the following: Social Services Department Office: UTHCPC 2A07 Phone: 741-5985 Related standards JCAHO MA 2, MA 3 JCAHO RI 1.1-1.2, RI 1.3.6 3-44 Printed 01/30/15
  45. 45. UTHCPC Policies and Procedures Therapy Assessment/Services Patient Care – Treatment Services Chaplain Assessment/Services Summary Date of Last Review 07/30/04 SME: Alvin Hodges The chaplain visits the patient to deliver pastoral services and to assure patient rights to religious expression. Chaplain visits may occur by consult request from the treatment team, by request from patients, their families or through spirituality groups and chapel services. Pastoral care consult Members of the treatment team may request a pastoral care consult for a specific reason such as the following: • Counseling to help the patient deal with a spiritual/religious problem, see Pastoral Care Consult (form is available for data entry in Sunrise) • Assessing the patient's treatment needs in light of the patient's cultural/spiritual/religious baseline, see Consult for Religiosity (form is available for data entry in Sunrise) • Providing supportive counseling • Helping the patient relate to a religious support community • Providing the patient with religious material Example: Bibles • Providing a sacrament or contacting a pastor of the patient's faith to provide sacramental ministry Example: Holy Communion or confession Consult request The treatment team, family, or patient can request consults through the Allegra system with a specific reason for the request. Chaplains will respond to consult requests within 48 hours of receipt. Patient consultation The chaplain does the following when consulting a patient: Stage Description 1 Interviews the patient and determines the cultural/spiritual/religious history 2 Determines the patient's present cultural/spiritual/religious beliefs and practices 3 Notes differences between past and present cultural/spiritual/religious beliefs and practices and clinically judges the patient's strengths and weaknesses 4 Suggests methods to increase the patient's strengths and decrease the weaknesses 5 Documents the assessments, treatment suggestions, and visits in the progress notes Continued on next page Printed 01/30/15 3-45
  46. 46. Therapy Assessment/Services UTHCPC Policies and Procedure Patient Care – Treatment Services Chaplain Assessment/Services, Continued Spiritual groups Chaplains visit patients at-large as time permits. Spiritual groups facilitate patient understanding of the benefits that spiritual self-assessment and spiritual coping skills offer for healing and mental health. The groups are age-appropriate and diagnosis- appropriate. Nondenominational chapel services The Chaplain offers worship services for the entire center on Sunday and on religious holidays. Related standards JCAHO MS 6.5, PE 1, PE 1.7, PE 4-4.3, PE 6, PF 1.1, RI 1.3.5 JCAHO PE 4-4.1, PE 6, PE 7, PF 1.1 RI 1.3.5 3-46 Printed 01/30/15
  47. 47. UTHCPC Policies and Procedures Therapy Assessment/Services Patient Care – Treatment Services Psychology Services Introduction Date of Last Review 02/12/04 SME: Dr. Patricia Averill As part of the multidisciplinary treatment, psychology consults are available to help the treatment team provide the best quality care for the patient. Request The attending physician of the treatment team can request psychology services for a patient evaluation and treatment by filling the Psychology Service Request in the physician order sheet. Assessment The following assessment services are available from the Psychology Department: • Cognitive/intellectual evaluation • Personality evaluation • Neuropsychological screening Psychotherapy The following are psychotherapy services available: • Individual – Adult Services only • Group – Adults, Child/adolescent Services • Training – Psychology residents and practicum students participate in all departmental services • Research – Applied research pursuant to the mission of the Medical School Questions If any staff member has further questions regarding Psychology Services, s/he should contact the following: Psychology Services Office: 2-D02 Phone: 741-3942 Related standards JCAHO PE 1-1.1 Printed 01/30/15 3-47
  48. 48. Therapy Assessment/Services UTHCPC Policies and Procedure Patient Care – Treatment Services Nutritional Assessment/Services Purpose Date of Last Review 02/12/04 SME: Dale Hardy The purpose of the nutritional assessment is to allow the physicians and other disciplines to have a simplified view of the patient's nutritional status and understand the registered dietitian (R.D.) recommendations. Food and Nutrition department The Food and Nutrition department provides food and clinical nutrition services to the patients under the direction of a director and registered dietitian (R.D.), respectively. Assessment and/or consult A patient nutritional assessment or consultation is triggered through the nursing assessment and/or physician order. The assessment or consultation includes, but is not limited to, the following: • Diagnoses • Patient weight • Diet order • Recommendations • Plan Counseling and/or education As part of a nutritional assessment, the R.D., in conjunction with the treatment team, determines appropriateness and need for counseling and education. Examples of conditions of appropriateness: • Modified Diet Order Example: 2000 calorie ADA, low fat, low cholesterol. diet. • Patient and R.D. preference for weight loss or weight maintenance • Medical conditions that requires nutrition advice Example: AIDS, pregnancy • Nutrient/drug interactions that are completed within 72 hours of the pharmacy notification Registered dietitian contact The dietitian is on-site for consultation and assessment Monday-Friday from 8:00 a.m. to 5:00 p.m. The dietitian is on-call for emergency consultation and assessment and can be paged through the operator when there is a physician order for an emergency nutritional consult. Examples of emergencies: • A patient with no intake for 24-48 hours • A patient with critical lab values that require an intervention Continued on next page 3-48 Printed 01/30/15
  49. 49. UTHCPC Policies and Procedures Therapy Assessment/Services Patient Care – Treatment Services Nutritional Assessment/Services, Continued Screening and assessment This table describes the process of screening and assessing a patient for possible nutritional risks: Stage Description 1 Upon admission, a registered nurse screens each patient to identify who is at nutritional risk using the screening criteria that the R.D. has developed. 2 Does the patient have possible nutritional risks? If yes, • The registered nurse notifies the registered dietitian via the computer under Nutrition Consult • Exceptions: – If the patient has had a nutrition consult within the last 6 months for the same condition, an assessment is not indicated unless the patient desires a consult. – If the patient is unwilling or unable to participate in an assessment, the treatment team initiates a request for a consult when appropriate. If no, then a Nutrition Consult is not needed. 3 The R.D. provides a nutritional assessment of the patient within 72 hours of notification during weekdays. 4 The R.D. documents the nutrition assessment in the assessment section and completes the Multidisciplinary Treatment Plan. 5 After the initial nutrition screening, the health care team can notify the R.D. as needed. Example: Nutrition related labs or any new nutritional-related information not revealed during the initial screen 6 The dietitian’s assessment is placed in the physician’s order section of the medical record for review and initialing. Follow-up The RD reassesses patients in accordance with the patient's level of nutritional risk within the following time frames or as needed: • Moderate risk within 5-7 days • High risk within 3 days Follow-up documentation The RD documents the follow-up in the progress notes reviews the Multidisciplinary Treatment Plan to evaluate the patient's progress toward nutrition-related goals. The RD reassigns and follows-up the nutrition risk levels as appropriate until discharge. Continued on next page Printed 01/30/15 3-49
  50. 50. Therapy Assessment/Services UTHCPC Policies and Procedure Patient Care – Treatment Services Nutritional Assessment/Services, Continued Food services Patients receive nutritional adequate, semi-selective meals three times a day. Snacks are provided between meals three times a day. Special food needs The Nutrition and Food department provides special diets and accommodates patient’s special needs. Example of special need: Religious, allergies, and ethnic Example of special diets: Low fat, low sodium and diabetic or combination Questions Staff and patients can contact the following for information regarding nutrition and food services/assessment: • Director, Food and Nutrition Office: UTHCPC 2-A34 Phone: 713-741-8628 • Clinical Dietitian, Food and Services Nutrition Services Office: UTHCPC 2-A32 Phone: 713-741-8624 Pager: 713-769-3663 Related standards JCAHO MS 6.5, PE 1, PE 1.2, PE 1.5, PE 1.7, PE 4-4.3, TX 4-4.7 JCAHO LD 1.7, LD 1.7.1, LD 2.3 3-50 Printed 01/30/15
  51. 51. UTHCPC Policies and Procedures Therapy Assessment/Services Patient Care – Treatment Services Pharmacy Services Introduction Date of Last Review 02/12/04 SME: Diane Winkler To ensure patient safety, the hospital Pharmacy stores, prepares, and dispenses drugs. Location The Pharmacy is located on the first floor of UTHCPC in room 1-A70. Hours of operation The hours of operation are 9:00 a.m. to 9:00 p.m. On-call pharmacist After 9:00 p.m., the on-call pharmacist is available by beeper at number 713-905-0071. Questions Any questions regarding use of drugs at UTHCPC should be directed to the Pharmacy. Telephone number 713-741-8610 or 713-741-8611 Further information If a staff needs further information regarding the Pharmacy, s/he should contact the following: • Director, Pharmacy Office: 1-D00 Phone: 713-741-7820 • Investigational Drug Information Office: 1-A70 Phone: 713-741-8610 Related standard JCAHO TX 3 Printed 01/30/15 3-51
  52. 52. Therapy Assessment/Services UTHCPC Policies and Procedure Patient Care – Treatment Services Social Services Group Process Referrals for groups Date of Last Review 02/12/04 SME: Joanie Amason-Norlund The admitting physician orders that the patient be assessed and involved in group therapy per criteria, as appropriate. Following an assessment by the Social Service Clinician, a group schedule is developed from the Multidisciplinary Problem Aggregate (MPA) using group criteria. Criteria for participation are as follows: • On-unit groups, GAF 20-30, oriented X3, no overt aggression/psychosis • Off-unit groups, GAF 30+, oriented X3, no overt aggression/psychosis • Individual treatment goals are established upon first contact with patient • All patients are provided educational opportunities through the Lifeskill Groups or Patient/Family Education Groups • Patients may be discharged from groups if they are unable to tolerate the treatment setting or they have reached maximum benefit Documentation Documentation is in the multidisciplinary progress notes. Group progress notes are comprised of the following: • Data – an objective measurable report of the patient’s behaviors • Assessment – The patient’s progress or otherwise according to the goal • Plan – steps that will be taken by the therapist to revised or continue the goal • Educational, didactic groups are documented on the Patient/Family Education Sheet and reflect the patient’s response in behavioral terms Continued on next page 3-52 Printed 01/30/15
  53. 53. UTHCPC Policies and Procedures Therapy Assessment/Services Patient Care – Treatment Services Social Services Group Process, Continued Groups The groups available for adult patients are: • Management of Mental Illness • Resource/Patient Education • Music Therapy • Recreation Therapy • Stress Management • Spirituality • Grief/Trauma • Women’s Issues • Relationship Group • Mood Management • Men’s Issues • Anger Management • Dual Diagnosis • Thought Disorder • Depression Groups for children and adolescents: • Substance Abuse • Anger Management • Stress Management • Grief/Loss • Self-Esteem/Goals • Creativity • Healthy Relationships • Surviving Abuse • Management of Mental Illness • Coping Skills Continued on next page Printed 01/30/15 3-53
  54. 54. Therapy Assessment/Services UTHCPC Policies and Procedure Patient Care – Treatment Services Social Services Group Process, Continued Clinicians for groups The clinicians provide psychotherapy groups for patients. Group psychotherapy requires the following staffing: • Assigned to specific units with cross-coverage • Social Services Clinicians rotate weekend coverage to facilitate hospital-wide groups for adults and unit-based groups for children and adolescents • All group psychotherapy is conducted by masters level clinicians that are licensed by the state of Texas (LMSW, LMSW-ACP, LPC) Accomplishments of recreational activities Recreation Therapists engage patients in recreational activities to accomplish the following: • To reduce stress and barriers to leisure involvement • To improve mood, reality orientation, focusing on tasks and problem-solving • To increase activity level • To improve interaction and communication skills, and acceptable demonstration of feelings/coping Recreational activities setup Assessments for recreational activities are initiated upon receipt of referral. They are unit-assigned. The reasons for the groups follow: • To provide opportunities for learning about new leisure activities • To emphasize importance of leisure activities in maintaining a balanced lifestyle Music therapy groups Music therapists provide a program in music therapy, combining the healing aspects of music with treatment goals to bring about desirable changes in behavior. • Assessments initiated upon receipt of referral • Unit-assigned • Facilitates greater insight to emotions and illness Pastoral services The chaplain provides pastoral services and assures patients’ rights to religious expression. Chaplain visits may occur by consult request from the treatment team, patients, families, or pastors, or through spirituality groups and chapel services. For questions For further questions regarding Social Services, call 713-741-5985. 3-54 Printed 01/30/15
  55. 55. UTHCPC Policies and Procedures Therapy Assessment/Services Patient Care – Treatment Services Pet Visitation Program Introduction Date of Last Review 02/12/04 SME: Susan Parnell Pet visitation is provided to patients to improve psychosocial well-being. Patient participation Patients may choose not to participate in the pet visitation program. Patients wishing to participate are evaluated by nursing staff for allergies prior to pet visitation and must wash their hands after handling or touching the animals. Sponsoring agency responsibilities Caring Critters and the Houston Zoo are the sponsoring agencies for the pet visitation program. These agencies have the following duties: • Pre-screen and perform periodic evaluation of participating animals for: – Enteric pathogens – Ectoparasites – Temperament • Keep animal’s vaccination records on file at the agency office • Ensure that dogs and cats remain on a leash or in a cage at all times • Contain other animals by a method appropriate to the type of animal Animals allowed for visitation The following animals are permitted at UTHCPC: • Dogs and cats from the Caring Critters Program • Selected animals from the Houston Zoo Exceptions: Raccoons, skunks, reptiles, non-human primates, or turtles are not allowed in the program. Reasons: These animals may carry rabies, enteric pathogens, or may bite. Areas off-limits for animals Animals are not permitted in the following areas: • Cafeteria • Units Note: Animals may not visit during patient mealtimes. The nutrition center must remain closed during animal visitation. • Medication room • Pharmacy • Exam rooms • Clean storage rooms and linen rooms Animal bites or scratches Nursing staff reports animal bites or scratches as follows: • Notifies the attending physician and treats • Documents on the Patient Care Variance Report form or Occurrence Report form, as applicable • Notifies the Infection Control Nurse Printed 01/30/15 3-55
  56. 56. Therapy Assessment/Services UTHCPC Policies and Procedure Patient Care – Treatment Services Related standard JCAHO IC 4 3-56 Printed 01/30/15
  57. 57. UTHCPC Policies and Procedures Therapy Assessment/Services Patient Care – Treatment Services Closed Circuit Telecasting Introduction Date of Last Review 02/12/04 SME: Suzanne Foster UTHCPC offers closed circuit telecasting to provide the following services: • Patient education and entertainment that is conducive to a therapeutic milieu • Family and staff education Telecasting services In addition to public television channels, UTHCPC provides access to three closed circuit (in-house) channels 7, 12 and 21. These closed circuit channels may be accessed from 8:00 a.m. until 10:00 p.m. by the following: • Patient units • Designated conference rooms • Lobby Note: National and local news may be accessed on public channels 2, 11, 13, and 8 at regular broadcasting times. Technical assistance Technical assistance is to be directed to the Public Information and Education department extension 7811. In-house program directory A directory of in-house programming is available from the Public Information and Education department and the Hospital-Wide Education department. Therapeutic milieu On the units, the closed-circuit channels are considered a priority over public television to provide patients with a therapeutic milieu. Use of these channels is determined by staff members in accordance to patient rights and needs. VCR use for tele-education VCRs on patient care units are for the use of approved clinical materials. The TV Subcommittee determines what material is appropriate for viewing on the units. Programming issues For programming issues or questions, contact the Hospital-Wide Education department extension 3879. Related standards JCAHO RI 1.3.6.1.1, PF 1.6, PF 1.10, PF 4-4.1 Printed 01/30/15 3-57
  58. 58. Evaluation and Testing UTHCPC Policies and Procedure Patient Care – Treatment Services EKG Process Summary Date of Last Review 03/11/04 SME: Arslee Mackey EKG results are required to support quality patient care. UTHCPC has established guidelines for ordering an EKG (electrocardiogram) for patients. Requesting an EKG The physician writes an order for the EKG. Daily directory The daily directory is a report generated by the EKG machine which lists the EKG’s performed daily. Generating results Nursing staff proceeds with the process of reporting EKG results as follows: Stage Description 1 Receives the physician’s order requesting an EKG. 2 Enters the order into the computer which generates an order number. A requisition is generated from the computer to the lab. 3 Signs out and obtains the EKG machine from the lab, room 1A72. 4 The Licensed Nurse or Psych Tech IV performs the EKG using the guide on the machine for placement of electrodes and leads and for data entry. 5 Upon completion of the EKG, the Registered Nurse reviews the rhythm strip and informs the physician of any abnormal finding(s). 6 Nursing staff files a copy of the rhythm strip in the medical record. 7 Nursing staff transmits the rhythm strip to a cardiologist for interpretation. 8 Within 48-72 hours, nursing staff receives a formal report and places it in the medical record. Continued on next page 3-58 Printed 01/30/15
  59. 59. UTHCPC Policies and Procedures Evaluation and Testing Patient Care – Treatment Services EKG Process, Continued Inquiries Inquiries about EKG reports can be directed to extension 7854 between the hours of 8:00 a.m. and 2:00 p.m., Monday through Friday. Related standard JCAHO IM 7 Printed 01/30/15 3-59
  60. 60. Evaluation and Testing UTHCPC Policies and Procedure Patient Care – Treatment Services EEG Request EEG technician availability Date of Last Review 03/11/04 SME: Arslee Mackey The EEG technician is available Monday through Friday and on-call evenings/weekends. Services The physician can request the following services by using the Physician’s Orders for Ancillary Services form: • Routine EEG • Sleep Deprived EEG • Auditory Brain Response (ABR) • EEG Brain Map • Visual Evoked Potential (VEP) • Somatosensory Requesting/ reporting process This table describes the process of requesting and reporting an EEG: Stage Description 1 The physician completes a written order on the Physician’s Orders for Ancillary Services form. 2 Nursing staff enters the order into the computer. 3 The order requisition prints in the EEG department and staff schedules the patient for the procedure. 4 The EEG department notifies the unit of the appointment date and time. 5 The EEG technician calls for the patient at his/her appointed time to perform the service. 6 EEG staff places the EEG report in the chart. Related standards JCAHO IM 7-7.1 3-60 Printed 01/30/15
  61. 61. UTHCPC Policies and Procedures Evaluation and Testing Patient Care – Treatment Services Nuclear Medicine Testing Approval Date of Last Review 03/11/04 SME: Dr. Roy Varner To ensure that nuclear medicine testing is in the patient’s best interest, the Medical Director must approve all requests for these tests. Testing available Diagnostic testing is available to patients at UTHCPC. The physician determines which tests the patient needs and then initiates a relevant physician’s order following the above approval. Diagnostic tests: Laboratory and other invasive and non-invasive diagnostic and imaging procedures Brain imaging In the case of requests for various brain imaging scan (CT, MR, SPECT), the following forms must be completed: • The attending physician completes and signs the Brain Imaging request form. • The attending physician writes a note indicating the value of the test to the management of the patient. Process This table describes the process of requesting the nuclear test: Stage Description 1 The attending physician, the unit secretary and registered nurse complete the required forms. 2 The unit secretary forwards the request to the Medical Director. 3 The Medical Director approves/disapproves and returns the form to the unit. Related standard JCAHO PE 1.4 Printed 01/30/15 3-61
  62. 62. Progress Notes and Physician’s Orders UTHCPC Policies and Procedure Patient Care – Treatment Services Progress Notes Introduction Date of Last Review 11/05/02 SME: Arslee Mackey Progress notes are written in the chart to document the patient’s status or achievements in aspects of treatment and discharge. Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Writing Sequence Progress note entries in the patient record are maintained in chronological order by date in the chart as follows: • Physicians begin all lines of their progress noting at the left edge of the progress note form. • Nursing staff begin all lines of their progress noting at the first indented line from the left edge. • All other disciplines begin progress notes at the second indented line from the left edge. Date and Time: Each note must begin with the date and time. Content Progress Notes address: • Documenting the patient’s current status in treatment • Significant change in patient’s condition • Significant change in patient’s diagnosis • The patient’s problem(s) prioritized by the physician on the master treatment plan. Example: The patient’s inability to tolerate uncomfortable feelings, alcohol withdrawal, defeating a problem-solving relationship with a spouse Progress notes may also include, but are not limited to, the following: • Treatment Team Meeting/Review • Results of Goal-Related Testing • Patient Response to Planned Intervention • Patient/Family Education • Unexpected Occurrence Related to Problems/Strengths • Results of Testing/Procedures • Progress Toward Discharge Continued on next page 3-62 Printed 01/30/15
  63. 63. Progress Notes and Physician’s Orders UTHCPC Policies and Procedures Patient Care - Treatment Services Progress Notes, Continued Quality of progress notes Progress notes should be easy for others to read. To ensure quality of progress noting do the following: • Record notes in black ink • Write legibly Date, time, discipline Each discipline writes the following: • Date, time (including a.m. or p.m.) • The discipline Signature, degree initials, title Each discipline signs his/her legal (employee roster) name followed by his/her license initials/degree initials/hospital staff title as appropriate. Documenting rules To access rules for documenting in the patient chart, see Medical Record Documentation. Forms Progress Notes Teacher Progress Notes - Adolescents Teacher Progress Notes – Children Teacher’s Weekly Progress/Feedback for Subacute Adolescent Services Related standards JCAHO CC 2.1 IM 7.1-7.2 PE 2.1 Printed 01/30/15 3-63
  64. 64. Progress Notes and Physician’s Orders UTHCPC Policies and Procedure Patient Care – Treatment Services Social Service Case Management Progress Notes Introduction Date of Last Review 03/11/04 SME: Joanie Amason-Norlund Social Service Clinicians use the multidisciplinary progress note forms to document their work with patients: • Initial progress note • Discharge note Information included These pre-printed forms provide a space for the date and time that the note is added to the medical record as well as spaces to document the following: • Contacts with patient • Contacts with others significant to treatment and discharge planning – Family/significant others/guardian – Community resources – Treatment team • Progress in treatment • Discharge plans • Further discussion When completed Initial Progress Note completion: The Social Service Clinician must complete the Initial Progress Note within 48 hours of the patient’s arrival to a given treatment unit. Summary Note completion: The Social Service Clinician completes the first Summary Note by the end of the fifth day of a patient’s stay. S/he completes subsequent Summary Notes are at least every seventh day thereafter. Continued on next page 3-64 Printed 01/30/15
  65. 65. Progress Notes and Physician’s Orders UTHCPC Policies and Procedures Patient Care - Treatment Services Social Service Case Management Progress Notes, Continued Discharge summary note At the time of discharge, the Social Service Clinician writes a “Discharge Summary Note” that summarizes the following: • Final arrangements for the patient’s residence • Aftercare • Medical care • Social support • Transportation after discharge from the hospital Discharge summary notes format: The Social Service Clinician may use the “Summary Note” format when the discharge coincides with the need for a weekly summary. Otherwise, s/he may use the following standard Progress Note format: • Date, Time, Discipline, Discharge Summary Note • A listing of final arrangements as outlined above • Signature and credentials of the Social Service Clinician Quality requirements See Legibility and Unacceptable Abbreviations Related standards JCAHO CC 2.1, IM 7.1-7.2, PE 2.1 Printed 01/30/15 3-65
  66. 66. Progress Notes and Physician’s Orders UTHCPC Policies and Procedure Patient Care – Treatment Services Social Service Group Progress Notes Introduction Date of Last Review 03/11/04 SME: Joanie Amason-Norlund Social Services staff document their work with patients in the Progress Note section of the medical record. Information The Social Services staff select some of the following information according to the type of the note required: • Date of note • Time of note • Date of group • Time of group • Master treatment plan number • Name of group • Data: gathered by observation and/or patient self-report • Assessment: measure of patient’s progress toward MTP goal • Plan: course of action for continuation of treatment i.e. action toward patient’s goal • Reason for patient not attending group, if applicable • Signature Progress note completion time The staff member must complete a progress note within 24 hours from scheduled group time. Quality requirements See Legibility and Unacceptable Abbreviations Related standards JCAHO CC 2.1, IM 7.1-7.2, PE 2.1 3-66 Printed 01/30/15
  67. 67. Progress Notes and Physician’s Orders UTHCPC Policies and Procedures Patient Care - Treatment Services Physician’s Orders Summary Date of Last Review 03/11/04 SME: Dr. Roy Varner Physicians or designees must follow UTHCPC guidelines when s/he calls for or writes orders for treatment. Only privileged physicians and residents may write orders or provide telephone orders. Orders Physician’s orders may be written to include, but are not limited to, the following: • Admitting provisional diagnosis • Laboratory/Diagnostic procedure order • Transfer/Discharge/Consultation • Medication order • Other treatment orders – Vital signs – Nutritional services – Precautions – Program services (e.g. groups) – Psychology services Telephone orders To ensure safe and adequate use of medications, telephone orders must be handled as follows: Stage Description 1 The medical practitioner determines that the patient is in need of an intervention, with telephone communication presenting the swiftest method of accomplishing the order. 2 Licensed staff records/documents the telephone order in red ink. 3 After writing the order and before it is carried out, the person who wrote the order reads it back to the physician verbatim. In the case of medication orders spell the name of the drug if it sounds like another drug. Example 1: Orders are transcribed in the metric system, excluding medication/therapies that use standard units such as insulin Example 2: The word “unit” is written, rather than the abbreviation “U” Example 3: For medications prescribed in micrograms, the word “micrograms” is written, rather than the abbreviation “mcg”. Continued on next page Printed 01/30/15 3-67
  68. 68. Progress Notes and Physician’s Orders UTHCPC Policies and Procedure Patient Care – Treatment Services Physician’s Orders, Continued Telephone orders (continued) To ensure safe and adequate use of medications, telephone orders must be handled as follows (continued): Stage Description 4 The person receiving such orders records the physician’s name, signs, dates, and times the orders immediately. Physician signature: The ordering physician or the attending physician must authenticate the order by discharge. Exception: Orders for seclusion/restraint or emergency psychoactive medications must be authenticated within one hour and must be done by the physician giving the order. 5 The order is transcribed by nursing staff. Requirements The physician must write orders clearly, legibly, and understandably. The pharmacy will not carry out any illegible or improperly written orders. Physician orders are recorded in black ink with the exception of telephone orders (red ink). Resident The attending physician reviews the physician residents' orders during the daily rounds supervisory activities. Medication use Abbreviations for medications may not be used on physician’s order forms. Any medications the physician orders and gives to patients must be listed in the following: • The current edition of United States Pharmacopeia • National Formulary • American Hospital Formulary Service • A.M.A. Drug evaluations Medication issuance/ administration Only privileged physicians and residents under their supervision can order medications. Only UTHCPC employees with appropriate licensure, certification, or registration can administer medications. Investigational drugs The physician can order and use experimental and investigational drugs only under the sponsorship and supervision of the UTHSCH-MS Department of Psychiatry’s research guidelines, and the UTHCPC Research Committee. Continued on next page 3-68 Printed 01/30/15
  69. 69. Progress Notes and Physician’s Orders UTHCPC Policies and Procedures Patient Care - Treatment Services Physician’s Orders, Continued Investigational drugs from another institution Patients admitted to UTHCPC who are taking investigational drugs under a protocol from another institution can receive such drugs at UTHCPC on a written order if the other institution has provided UTHCPC with the following: • A copy of the protocol • A copy of the patient’s original informed consent • Adequate written information about its pharmacology as follows: – Adverse effects – Storage requirements – Method of dose preparation and administration – Precautions to be taken – Authorized prescribers – Patient monitoring guidelines – Any other material pertinent to the safe and proper use of the medications Consultation The physician must request consultation on critically ill patients when the diagnosis or appropriate treatment is obscure or cannot be obtained at UTHCPC. The attending physician provides a written order requesting a consult for the patient. Forms Physician’s Admitting Orders Physician’s Orders Physician’s Orders for Seclusion/Restraint Physician’s Order for Admitting Provisional Diagnosis Physician Order for Ancillary Services Related standards JCAHO PE 1.11, IM 7.2, IM 7.7-7.8 Printed 01/30/15 3-69

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