Documentation: We continue to see Care Plans that are not updated &/or not specific as to what teaching has been done – make sure Care Plans are patient specific & updated @ least Q24hrs (i.e. Care Plan cannot state you educated patient about “Meds” & patient needs reinforcement – you must list specific medication name(s) so that next shift can look at care plan & know what education is needed; also remember that you must document the patients understanding of education)
Core Measure Highlights – Starting 10/01/2010, we will be monitoring AMI charts for Statins prescribed at discharge or contraindication documented. A list of common Statins along with checkbox for this measure has been added to Core Measure Checklist so that you can begin monitoring now so that you will be familiar with this measure. For June we were 100% on AMI & Pneumonia measures, but continue to struggle with SCIP & CHF. Failures are as follows:
· CHF Discharge Instruction – Two failures related to computers being down & discharge instructions failed to address weight monitoring & symptoms worsening. All CHF patients should be receiving CHF teaching sheet & this should be documented as being given to the patient. We have updated the Core Measure Checklist to include all six items that must be addressed at discharge (diet, activity, weight monitoring, follow-up appt; symptom worsening & medication list) & have also updated a specific CHF discharge instructions sheet for use when computers are down.
· SCIP– Remember to carefully read your post-op orders & perform chart checks – Antibiotics should routinely by discontinued within 24hrs of surgery (unless there is a documented post-op infection)
· SCIP – Foley Catheter removed by POD 2 or documentation of contraindication to remove. If there is an order to remove the Foley Catheter then you must remove it or obtain a new order for it to remain in place. Failures in both June & July related to nursing not carrying out orders in a timely manner.
Remember - The Core Measure Checklist MUST be completed on ALL core measure patients (2 signatures required) & for CHF patients you MUST have one of the following double check medication lists prior patient discharge: Clinical Coordinator, Director, Nursing Supervisor or Quality personnel.
Teena Meeks - OR |
Delilah Parker - ICU |
Rita Rabitt – M/S/T |
Pauline Francescone – ER |