Download Task 11-Medical Record Review

Patient Assessment,
Plan of Care, and
Medical Records
Kelly Frank, RN, BSN
Health Facilities Surveyor
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Objectives For This Session
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Describe the required components of patient
assessment and patient plan of care in the
new ESRD CfCs
Identify the expected timelines for completion
of the patient assessment and patient plan of
care
Describe the medical record documentation for
the patient assessment and plan of care
2
We Are Playing Different Positions On
the Same Team… And the Goal Is…
Improving
patients’
well-being
through
improved
outcomes!
3
Change in Focus: Patient
Assessment & Patient Plan of Care
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From LTP/PCP to PA/POC
Hard to talk about PA without talking about
POC
NOT about paper!
About collaboration of the interdisciplinary
team (IDT)
About better outcomes for the patient:
“attain and sustain”
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Outcomes Based on ESRD
Clinical Practice Standards

Developed by renal community workgroups &
coalitions; e.g.
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National Kidney Foundation Kidney Disease
Outcomes Quality Initiative (NKF KDOQI)
Guidelines
National Quality Forum (NQF): Clinical
Performance Measures (CPM)
Address management of complications of
ESRD
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Measures Assessment Tool
(MAT)
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The MAT is a tool developed for ease of
reference to these Clinical Practice
Standards
MAT was deliberately developed for ease
in updating
If an individual patient does not meet a
goal on the MAT, the plan FOR THAT
ASPECT of care must be revised
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Patient Assessment &
Patient Plan of Care
These 2 Conditions:
 Are interrelated (“can’t have one without
the other”)

Address patient assessment & care
delivery requirements in “care areas”
associated with complications of ESRD
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Patient Assessment and
Plan of Care
Best Friends Forever
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The New Conditions Place High
Expectations on Facilities for
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Interdisciplinary approach for continually
assessing individual patient’s care needs,
and for planning and implementing the care.
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Outcome goals that meet current
professionally-accepted clinical practice
standards
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Interdisciplinary Care vs.
Multidisciplinary Care
Interdisciplinary
Work collaboratively
Multidisciplinary
Work sequentially
Communication by regular
discussions about patient
Medical record is the chief
status & the evolving plan of means of communication
care
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Interdisciplinary Team
Collective vs.
Individual
Problem Solving
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Interdisciplinary Team (cont.)
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Includes at a minimum:
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The patient or his/her designee
A registered nurse
A physician treating the patient for ESRD
A masters prepared social worker
A registered dietitian
Required for both patient assessment and
plan of care
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Patient Assessment § 494.80
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The interdisciplinary team (IDT) must collaborate to
provide each patient an individualized
comprehensive assessment
14 assessment “criteria”
Most required sections do not specify “who” must
conduct the assessment
Reassessments required at defined frequencies
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“Unstable” = monthly
“Stable” = annually
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Patient Plan of Care § 494.90
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The IDT must develop & implement a written,
individualized comprehensive patient plan of
care (POC)
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Based upon the comprehensive assessment
Addresses each patient’s care needs
Outcome goals in accordance with clinical
practice standards – MAT
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Stable / Unstable
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Stable patients: annual comprehensive
interdisciplinary reassessment
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Unstable patients: monthly comprehensive
interdisciplinary reassessment
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POC updated & implemented within 15 days
POC updated & implemented within 15 days
All patients: continuous monitoring of any aspect of
care where the target is not met & revision of that
aspect of POC
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Who Is “Unstable?”
Includes but is not limited to:
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Extended (any stay >15 days) or frequent
hospitalization (>3 hospitalizations in a
month)
Marked deterioration in health status
Significant change in psychosocial needs
Concurrent poor nutritional status,
unmanaged anemia & inadequate dialysis
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In Between Assessments…
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Every patient must be continuously
monitored.
If a “stable” patient’s outcomes do not meet
the care plan goals in an area, the facility
must recognize and address that aspect
by revising the plan of care for that aspect
between comprehensive reassessments.
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Correlation of PA & POC
PA
POC
1. Current health status (V502)
2. Lab profile (V505)
3. Medication/immunization history
(V506)
Incorporated into all POC tags
4. Appropriateness of dialysis
prescription (V503)
Adequate clearance (V544)
5. BP/fluid management needs
(V504)
Manage volume status (V543)
6. Assess anemia (V507)
Manage anemia (V547)
Home pt ESA (V548)
ESA response (V549)
7. Assess renal bone disease
(V508)
Manage mineral metabolism
(V546)
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Correlation of PA & POC
PA
POC
8. Nutritional status (V509)
Effective nutritional status (V545)
9. Psychosocial needs (V510)
10. Evaluate family support (V514)
Psychosocial counseling/referrals/
assessment tool (V552)
11. Access type/maintenance
(V511)
VA monitor/referral (V550)
Monitor/prevent failure (V551)
12. Evaluate for self/home care
(V512)
Home dialysis plan (V553)
13. Transplantation referral (V513)
Transplantation status: plan or why
not (V554)
14. Evaluate current physical
activity level & voc/physical
rehab (V515)
Rehab status addressed (V555)
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For Each of the Care Areas
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IDT must assess each patient, develop &
implement POC to achieve established
targets
Goals based on current clinical practice
standards – MAT
If expected outcomes are not achieved, in
any area, IDT must recognize and address
this aspect
Must adjust the plan/implement the changes
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Current Health Status &
Medication History
Assessment
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Medical & nursing histories & physical exams
Must include etiology of kidney disease & listing
of co-morbid conditions
Initial review of current medications & allergies
Ongoing assessment of home medications
Plan of care for these aspects is addressed in
other care areas
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Immunization
Assessment: evaluate the patient for
 Immunization history/status for hepatitis ,
influenza, pneumococcal pneumonia
 HBV, tuberculosis screening
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Must know HBV status on admission or tx as positive
Plan of Care: offer the patient
 Influenza & pneumococcal vaccines
 HBV vaccine for all susceptible patients
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Retest vaccinated patients for response
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Blood Pressure &
Fluid Management
Assessment:
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Patient’s B/P on & off dialysis
Interdialytic weight gains
Target weight & intradialytic symptoms
Plan of Care:
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Achieve targets in fluid/weight management – MAT
Symptomatic drops in BP or continued hypertension
during dialysis require plan revision
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Anemia Management
Assessment: evaluate the patient’s:
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Laboratory values for Hgb, Hct, serum ferritin,
transferrin saturation
Associated co-morbid conditions
Appropriateness for ESA &/or iron therapy
Plan of Care: provide care aimed at
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Achieving established targets in anemia
management – MAT
Adjusting medications as indicated (may use
algorithms/ESA protocols)
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Nutritional Status
Assessment by dietitian: see list at V509
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Albumin
Body weight
Plan of Care: provide care & counseling
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aimed to:
Achieve & sustain effective nutritional status
(V545) - MAT
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CKD Mineral Bone Disorder
Assessment: evaluate the patient’s:
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Laboratory values for calcium, phosphorus, iPTH
Relevant dietary factors
Need for medications: phosphate binders, vitamin D
analogs, calcimimetic agents
Plan of Care: provide care aimed to:
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Achieve established targets (calcium, phosphorus,
iPTH) in CKD-MBD management – MAT
Adjust medications as indicated; may use
guidelines/algorithms
Provide dietary education/counseling as indicated
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Dialysis Adequacy
Assessment: required for every patient:
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HD: initial & monthly Kt/V (or equivalent measure, URR)
PD: initial & at least every 4 months Kt/V (or equivalent
measure, none currently)
Plan of Care:
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Prescribe treatment aimed at achieving HD spKt/V of at
least 1.2 (3 tx/week); PD Kt/V of 1.7; or
Modify the dialysis prescription; or
Provide a rationale for not achieving the expected target
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Dialysis Access: Assessment
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Assessment for most appropriate access for that
patient: AVF, AVG, CVC, PD catheter
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Evaluation for/of HD access:
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Consider co-morbid conditions/risk factors, patient
preference
Communicate with radiologist, interventionist, vascular
surgeon
Do venous mapping, place new access as indicated
Evaluation of PD access
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Absence of infection: exit site/tunnel, peritonitis
Patency & function
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Dialysis Access: Plan of Care
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Patient evaluation as candidate for AVF
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If CVC >90 days, action plan for a more
permanent vascular access or rationale for
continued use
Vascular access monitoring:
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To ensure capacity to achieve & sustain adequate
dialysis treatments
For early detection of failure &
Timely referrals for interventions
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Psychosocial, Functional Status
& Modality Needs: Assessment
Evaluation by SW: see list at V510
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Abilities, interests, preferences, goals for
participation in care, modality & setting
Family & other support systems
Physical activity level
Referral for vocational & physical rehab
Suitability for transplant referral based on
area transplant center criteria
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Psychosocial, Functional Status
& Modality Needs: Plan of Care
Counseling and referral as indicated
 Address physical & mental functioning &
rehab needs
 Home care plan (or why not)
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Transplantation referral (or why not)
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Timelines: All Began 10/14/08
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Initial comprehensive interdisciplinary
assessments for new patients:
• PA = 30 days/13 treatments whichever is later
• POC implemented within this same timeline
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Comprehensive reassessment for new patients:
• 3 months after initial assessment completed
• POC updated & implemented within 15 days of
reassessment
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What About Current Patients
on October 14, 2008?
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Need a plan to implement this new system
Complete some assessments/POCs each
month until all are done
All current patients should be included in the
new system by 10/14/09
Three month reassessments for current
patients are NOT expected
Any aspect of care that does not meet targets
must have an updated POC
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What’s Wrong With These
Pictures?
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The ESRD Medical Record
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Format
- Electronic, manual, combination
Content
- Consents
- Histories/medical exams
- Progress notes
- Labs
- Treatment orders
- Dialysis treatment records
- Patient education
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Medical Record
Documentation
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Patient assessment
Patient plan of care development/revision
Plan of care implementation
May be found in multiple parts of the record
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Use of the Mat
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Quality Patient Care Is About
the Process…Not the Paper
Patient
Assessment
Plan of Care
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[email protected]
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