Download - Van Wert County Hospital

VAN WERT COUNTY HOSPITAL
VAN WERT, OHIO
Policy/Procedure:
Departmental
Issue Date: 12-05
By: Case Management
Reviewed: 1-14, 1-11, 1-10
No: N 1-02
No. of Pages: 2
Revised:
Distribution List: All Nursing Departments
Concurrence:
Subject: Logicare Teaching and Discharge Instructions (excluding Emergency Dept)
Policy: All patients will be provided printed information related to their
diagnosis
medications
treatments
pre and post procedure instructions
discharge instructions
A computerized Logicare program is available to assist staff in providing patient/significant other
education on the medical/surgical unit and in the telemetry unit.
Purpose: To provide information to our patients &/or family to have enough knowledge:
to make appropriate healthcare decisions
to be able to be involved and participate in their healthcare.
May be Performed by: Admitting nurse or other nurse
(Forms may be printed from computer by tech, assistant, or clerk)
Procedure:
A. On computer admitting nurse, tech, assistant, clerk or other nurse to:
1. Log into Logicare system
2. Select daily teaching
3. Enter patient data
4. Select “Illness/Diagnosis”, “Procedure”, or “Discharge Inpatient” as needed
5. Search for:
a. the patients admitting diagnosis as listed by the admitting Physician.
b. ordered tests/procedure
c. final primary diagnosis (see “D” below)
6. Print material
B. Upon admission:
1. Admitting nurse is responsible for presenting illness/diagnosis information to the
patient/significant other
2. Allow patient/significant other to ask questions
3. Encourage discussion between patient/significant other and nurse related to diagnosis and
treatment plan
N 1-02
Logicare Teaching & Education
Page 2
C. Prior to testing / procedures:
1. Primary or nurse is responsible for presenting testing/procedure information to the
patient/significant other when the test/procedure is ordered
2. Present information to the patient/significant other
3. Allow patient/significant other to ask questions
4. Encourage discussion between patient/significant other and nurse related to test/procedure
D. Upon discharge:
1. Charge nurse or nurse discharging patient is responsible for presenting discharge instructions
a. from the Logicare system
b. from a preprinted discharge instruction form designed for that diagnosis by our facility
2. How to individualize discharge instructions:
a. Review patients chart to determine final diagnosis listed on form 6010-102, on most
current physicians progress notes or on face sheet as final diagnosis
b. Follow “A” above
c. On the first page after the disclaimer entitled IMPORTANT create new heading as
follows:
Medications: (including dosages, frequency, and any changes from admission)
Discontinued
Continued
New
What has been taken by the patient already today
Note: you do not need to print education on all medications; only the new
medications require printout
d. Complete instructions related to activity, diet, etc
i. clicking on insert on the top tool bar
ii. or by using the Icons on the left
e. Also include special instructions such as drains, pumps, dressing changes, follow up
testing, etc
E. If necessary to edit or add new material in Logicare
1. Submitted items to the Unit Director for approval
2. If approved send to designated editors who have been trained and have a password for this task
F. In the event that the computer is “down”
1. Several volumes of notebooks are available with most of the Logicare information in them
2. Notebooks are currently stored on the fourth floor Medical Surgical Unit
3. Each computer Screen is identified in the notebooks and may be used to provide information via
copies to the patient
4. The patient Discharge Information Form (#6010-016) may be substituted for discharge
information if the computer is down
Documentation:
A. One copy of the printed material is to be given to the patient/family
B. The smaller font copy is to be placed in the medical record
C. Discharge instructions then should be signed by the patient and discharging nurse and placed in the
medical record