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

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Discussion of Care Planning using SNOMED-CT codes and terminology

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Care planning presentation 13

  1. 1. Snow What? Care Planning with SNOMED INNOVATIONS ‘13
  2. 2. SpeakerSpeaker Lisa Rabideau, RN, BS, CPAN Clinical Informatics Manager CVPH Medical Center Lisa Rabideau has completed commercial bias disclosure forms and do not have any conflicts of interest.
  3. 3. Objectives  Define Care Planning  Contrast current care planning process to future requirements  Demonstrate use of SNOMED- CT terminology  Describe the future of Interdisciplinary Care Planning
  4. 4.  It is the policy of Corexcel and IMNE to ensure fair balance, independence, objectivity, and scientific rigor in all programming.  In compliance with the American Nurses Credentialing Center (ANCC) and the Accreditation Council for Pharmacy Education (ACPE), it is the policy of Corexcel and IMNE that faculty disclose all financial relationships with commercial interests over the past 12 months.  Corexcel’s provider status through the ANCC and IMNE’s provider status through the ACPE, are limited to educational activities. Corexcel, IMNE, ANCC and ACPE do not endorse commercial products.
  5. 5.  Open on current site 1926  Total licensed beds: 409  313 Acute Care beds  34 Psychiatric/Mental Health beds  96 Skilled Nursing Beds  42 temporary  >2300 employees,  521 RNs, 32 ISS staff, 163 physicians  Beautiful Midtown Plattsburgh, NY CVPH Medical Center
  6. 6. Nursing Documentation In the Beginning…  SOAP  APIE  PIE  Focus  Graphic flow sheets
  7. 7. From one extreme to the other
  8. 8. More Recently…  Checkboxes  Data Elements  Charting by Exception (CBE)
  9. 9. Need to Strike a Balance  Data elements for reporting  Notes to tell the patient story
  10. 10. Nursing Care Plans  Intended to be plan to provide care  Paper or Computerized  NANDA, NIC, NOC, CCC, PNDS  Done because you have to  Standardized - Individualized
  11. 11. According to the “Book”  Read the nurse’s admission assessment/history and the medication record  Review the history, current diagnostic test results, nurse’s notes for the last 48 hours, progress notes of providers and current consultation reports  Interview the patient and complete an assessment  Read about the diagnosis  Select the appropriate standardized care plan  Select the nursing and collaborative diagnoses that are appropriate  Modify the desired outcomes so they are measureable and realistic  Select the nursing actions that are relevant Ulrich, S. Canale, S. (2005) Nursing Care Planning Guides. Elsevier Saunders: St. Louis, MO.
  12. 12. What really happens:  Assessment generates standard problem  Nurse reviews problems and chooses plans  Plans are pre-set with nursing orders  Generally not customized  At pre-determined interval, nurse clicks “mark reviewed” on plan of care page  Generates a clinical note with no relevant content.
  13. 13. Takes up space Annoys providers
  14. 14. Influencing the Transition…  Meaningful Use Stage 1  The number of patients … who have at least one entry (or an indication that no problems are known for the patient) recorded as structured data in their problem list.  ICD-9 or SNOMED-CT  Threshold 80%  MU Stage 2  Part of Transitions of Care  SNOMED-CT required  Threshold 65% of Transitions of Care electronically transmitted
  15. 15. Moving from Nursing Care Plans to Interdisciplinary Problem List/Plan of Care  Currently used by Nursing  Consult orders go to other services  Documenting done primarily in assessments, some on paper
  16. 16. Initial Step  Took list of existing Nursing Care Plan Problems  Found appropriate SNOMED problem  Re-mapped and re-named problems
  17. 17. Example of Crosswalk Current Problems in Test Current Problems in Prod SNOMED options Knowledge deficit of community resources Special educational needs Knowledge deficit of discharge planning Knowledge deficit of discharge planning Special educational needs Knowledge deficit of smoking habit Knowledge deficit of Smoking habit Smoker Knowledge deficit of therapeutic regimen-diabetes mellitus Knowledge deficit of therapeutic regimen-diabetes mellitus Special educational needs Skin integrity impairment Skin integrity impairment Broken skin, tear of skin, pressure sore of (site), decubitus ulcer Skin integrity impairment risk Skin integrity impairment risk Infection Infection Infection, Infection due to resistant organism Infection risk Infection risk Immunodeficiency disorder, nutritional deficiency, neutropenia etc
  18. 18. Problem Name Mapping Problem SNOMED Nutrition Deficit Risk Nutrition Impairment Injury Risk Fall Risk Fluid Volume Impairment Edema Acute Pain Acute Pain Infection Problem-Potential At Risk for Infection Knowledge Deficit-Smoking Smoker-Current Smoker Anxiety Anxiety Skin Integrity Impairment Risk Risk for Impairment Impairment Skin Integrity Actual Chronic Ulcer of the Skin Activity Intolerance Risk Mobility Impairment Breathing Pattern Impairment Respiratory Distress Body Weight Impairment-Bariatric Obesity Sleep Pattern Impairment Disturbance in Sleep Behavior Knowledge Deficit Therapeutic Regimen- Diabetes Diabetes Mellitus Chest Pain Acute Chest Pain Comfort Care Dying Process
  19. 19. Problems not in “Starter Set”  Entrapment Precautions  Elopement Precautions  Comfort Care, Dying Process (added manually)  Restraints
  20. 20. Care Plan Orders  Met with sub-group of Nursing Documentation Team  Edited care plan orders to minimize duplication, redundancy  Reviewed existing plans 1 by 1
  21. 21. CPOE Order Sets  Contain Nursing Orders for appropriate problems.  Use of Nursing “Protocols”  Drive “Problem Order” to Plan of Care
  22. 22. Protocol Content A. Assessment: 1. Assess the location, radiation and duration of pain. 2. Assess intensity of pain on scale of 0-10. 3. Assess quality of pain (pressure, throb, heavy, burn, ache, sharp). 4. Identify events leading to episode of pain. 5. Assess EKG & telemetry strips for irregularities and ST changes. 6. Monitor blood pressure, apical pulse. 7. Monitor respiratory rate, character, and oxygen saturation. 8. Monitor skin color and temperature, presence of diaphoresis. 9. Monitor LOC (level of consciousness). B. Interventions: 1. Provide oxygen to the patient during chest pain episodes and next 24 hours. Re-evaluate according to oxygen protocol. 2. Assess the need for nitrates, antacids, and analgesics. 3. Call for a STAT EKG to be done according to criteria outlined in General Information. 4. Implement patients coping strategies in reducing pain. 5. Assess blood pressure after EKG if no relief of pain. 6. Administer nitroglycerin per orders. 7. Provide a calm environment. a. Turn lights to dim. b. Utilize patient support systems in reducing anxiety as appropriate. c.Turn off television or any other excess noises.
  23. 23. Other Nursing Measures  Addressed in Order Sets  Addressed in Standards of Care
  24. 24. Comfort Care CPOE Order Set
  25. 25. Standards of Care  Use Marker Model of structure, process and outcome standards  Address nursing process (APIE), Basic needs (activity, nutrition, elimination, sleep, comfort), Safety and Health management (including education)
  26. 26. Move to Interdisciplinary Plan of Care  Using plan of care display for multidisciplinary rounds  Start with Respiratory and Discharge Planning  Document clinical note from Care Plan under pertinent section of care plan problem.  Clinicians have clearer “patient story”
  27. 27. EDIS & Provider Documentation  Problem list now populated with both nursing and medical problems  Sometimes the same  Learning curve for nursing and providers
  28. 28.  Problems populated list  Plans need to be selected if appropriate
  29. 29.  Open problem to see source  In this case it is Primary Complaint
  30. 30.  When note charted from problem, problem name is attached to note
  31. 31. Problems Needing Care Plan Orders  Pneumonia  Heart Failure  DKA
  32. 32. Resources  AHIMA Workgroup. "Problem List Guidance in the EHR." Journal of AHIMA 82, no.9 (September 2011): 52-58.  CVPH Medical Center Community Service Plan September 2012  Dykes, P., DaDamio, R., Goldsmith, D., Kim, H., Saba, V. Leveraging Standards to Support Patient-Centric Interdisciplinary Plans of Care. AMIA Annual Symposium Proceedings 2011; 2011: 356–363.  Matney, S., Warren, J., Evans, J., Kim, T., Coenen, A., Auld, V. Development of the nursing problem list subset of SNOMED- CT. Journal of Biomedical Informatics. doi:10.1016/j.jbi.2011.12.003  Patient Services Standards of Care (2013), CVPH Medical Center, Plattsburgh, NY  Ulrich, S. Canale, S. (2005) Nursing Care Planning Guides. Elsevier Saunders: St. Louis, MO.
  33. 33. Soarian Clinical Solutions Track 2 Session # 11 Thank you for attending this session. Please take a few moments to complete your evaluation form before you leave. Presentations can be downloaded at: www.usa.siemens.com/InnovationsIT

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