Provision of Care Treatment and Services Chapter Leadership Presentation Pat Lavin

Assessments & Reassessments 1. Duplication of data collection Needs to be more interdisciplinary Need to determine who is asking what questions to eliminate duplication Collect data once with clear documentation of who collected the data

History and Physical Need a way to document that exam done and there were no changes from the initial history and physical

Pain Assure that the proper pain assessment tool for the patients used Reassessment of pain after treatment in NON-EMAR areas Epidural policy: current policy has different monitoring guidelines than orders. Need policy to have L&D differences in practice separated from main policy

Education of Patients All disciplines must know that the patient’s learning needs assessment is in the nursing assessment and have access to it All disciplines when teaching must individualize the education to the patient’s assessed needs AND then document education provided and the patient’s understanding of the teaching

Education of Staff 1. The hospital educates staff how to identify possible signs of abuse or neglect and their roles in follow-up (HR ,EP5) ? Hospital orientation vs Discipline Specific Orientation 2. An evidence-based training program is used to train staff to recognize the need for and use of resuscitation equipment. Policy pending

Recognition & Responds to Patient Conditions The hospital develops written criteria describing early warning signs of a change or deterioration in a patient’s condition and when to seek further assistance Policy pending

Handoff Communication The process of handoff communication provides for the opportunity for discussion between the giver and receiver of patient information Update policy to reflect policy regarding break handoffs and review policy with staff.

Restraints New interpretation of definition of a chemical restraint Restraint form needs revision Communication to staff