Initiation and Modification of Therapeutic Procedures Maintain Records and Communicate Information

Without proper record keeping  The therapy you provide may not be reimbursable  The hospital may get cited for improper record keeping  Your patient may be harmed

CRT EXAM  Requires knowledge of may facts, standards, and requirements for maintaining records and communication with other health care workers, patients, and family members  Requires application of the rules and standards for record keeping and communication while paying close attention to detail  Areas of emphasis include charting rules and standards, communication and coordination of patient care, and patient education, including smoking cessation education

Accept and Verify Patient Care Orders ACCEPTING ORDERS If you accept orders:  They must come from an authorized health care provider with prescribing privileges.  You cannot accept orders transmitted to you via unauthorized third parties (i.e. RN’s)  If transmitted via a third party you must verify the order in the patient’s chart  You should not accept blanket orders (e.g. “continue previous medications”

Accept and Verify Patient Care Orders VERIFYING ORDERS  It is your duty to assure that all respiratory care orders are accurate and complete  If an order is incomplete or fails outside established institutional standards you should contact the prescriber for clarification before implementing the request

Recording Therapy and Results BASIC RULEs FOR MEDICAL RECORD KEEPING  Good record keeping begins with careful attention to detail, requires proper use of terminology and abbreviations, and involves knowledge of how to make needed corrections or deletions to a patient’s record  NBRC expects that you know all the standard respiratory care abbreviations and symbols used on the exam.  Guidelines for Authors, Respiratory Care Journal Guidelines for Authors, Respiratory Care Journal

Recording Therapy and Results SPECIFYING THERAPY ADMINISTERED  “if it wasn’t charted, it wasn’t done”  Whenever you provide therapy to, or obtain diagnostic information from a patient, you must record the relevant details and, as necessary, communicate this key information to other members of the patient’s health care team

Recording Therapy and Results NOTING AND INTERPRETING THE PATIENT’S RESPONSE TO THERAPY  Effects of therapy, adverse reactions, and patient’s subjective and objective response  What you need to chart depends on  The expected outcomes of the prescribed procedure  What parameters you should be monitoring prior to, during, and after the procedure  What measures are available to evaluate the expected outcomes  The NBRC expects that you will properly chart any adverse reactions the patient may exhibit during or after the procedure

Recording Therapy and Results NOTING AND INTERPRETING THE PATIENT’S RESPONSE TO THERAPY (cont.)  Essentially all this key information for most respiratory care procedures is provided in the AARC clinical practice guidelines  Each guideline provides pertinent information on  Expected outcomes (Indications and Assessment of Outcomes)  What to monitor (Monitoring)  What adverse reactions to look for (Hazards/Complications)

Recording Therapy and Results SOAP NOTES  When using this method it is best to phrase your plan element of your chart entry as a recommendation  You should incorporate SOAP actions into your daily clinical care, and whenever responding to NBRC Exam questions

Recording Therapy and Results VERIFYING COMPUTATIONS AND NOTING ERRONEOUS DATA  All computations must be precise and accurate  Use the proper tools and techniques for precision  Check your results to ensure accuracy  Never report data about which you are unsure  You must be able to  Recognize and/or deal with conflicting data  Recognize plainly incorrect data  Identify and derive essential but missing information

Recording Therapy and Results VERIFYING COMPUTATIONS AND NOTING ERRONEOUS DATA (cont)  You must know how to apply common formulas and equations that appear on the Exam.  Whenever a question involves any numeric data you should:  Inspect the data for obvious errors  Inspect the data for discrepancies  Review the numbers to see what, if anything, is missing

Communicating Information The NBRC assesses your communication skills in:  Reporting the patient’s clinical status  Coordinating the patient’s care  Planning for patient discharge

Communicating Information You should communicate directly to the physician as soon as possible when  Your written plan includes any recommendations for a change in therapy  Any unexpected response to therapy or adverse effects are noted The more serious the problem, the sooner the key personnel (attending physician and nurse) must be informed If it is clear the patient’s vital signs are deteriorating, you should call for the rapid response team

Communicating Information You should also participate in coordinating the patient’s care  Work with the patient’s nurse and/or physician to schedule the therapy you provide at times:  Least likely to conflict with other treatments, tests, or meals  Most likely to coincide with either the administration or holding of medications

Explaining Planned Therapy and Goals to Patients To provide effective respiratory care you must properly explain to your patients both what needs to be done and why. Exam focuses on your ability to “translate” therapeutic goals and/or procedural terminology into terms a layperson can understand  Know the methods and expected outcome of the applicable procedures  Be able to use appropriate language to express this information the patients and their families The key is to always avoid using medical terminology.

Communicating Results of Therapy and Alter Therapy According to Protocol When implementing a protocol, make sure you are familiar with  The limits (boundaries) within which you are permitted to make independent adjustments  What conditions require physician notification

Educating Patient and Family Exam focuses on providing education on smoking cessation and disease management.  Assessing the patient’s learning needs (i.e. desire to quit smoking)  Educational strategy based upon the five R’s  Relevance  Risks  Rewards  Roadblocks  Repetition

Common Errors to Avoid on the Exam  Never accept an incomplete order, a blanket order, or an order transmitted to you via an unauthorized third party  Never use medical or technical terms with patients or their families when explaining procedures or providing patient education  Never erase entries in a medical record; instead always line it out and write “error” above the line-out  Avoid using any banned abbreviations and request clarification if an order contains them  Never allow unauthorized individuals access to any patient’s health care information.

Exam Sure Bets  Always read back and confirm a telephone order, and note the phone order in the chart  Always contact the physician and request an explanation before proceeding with any order that falls outside established standards, such as normal drug dosage  Always document each patient encounter with an assessment of the intervention and the patient’s response to it

More Exam Sure Bets  Always chart a patient’s refusal of therapy and reason, if provided  Always communicate any recommendations for a change in therapy directly to the prescribing physician as soon as possible  Always verify that the appropriate information has been received by those to whom you “handed off” a patient

More Exam Sure Bets  Always notify the physician if any significant change occurs when managing a patient via a respiratory care protocol  Always respect the patients’ privacy rights and their right of access to their own health information  Always recommend both counseling and pharmacologic support for patients who desire to quit smoking

Reference: Certified Respiratory Therapist Exam Review Guide, Craig Scanlon, Albert Heuer, and Louis Sinopoli Jones and Bartlett Publishers