HOW TO USE THE CLINICAL PATHWAY

Transcription

1 1. 2. INCLUSION CRITERIA: All Stroke patients over 18 years of age admitted to hospital. HOW TO USE THE CLINICAL PATHWAY This is a proactive tool to avoid delays in treatment and discharge. These are not orders, only a guide to usual order. Place the Clinical Pathway in the nurses clinical area of the chart. All health care professionals should fill in the master signature sheet at the front of the Pathway. Addressograph/sticker each page of the Pathway. 3. MULTIDISCIPLINARY TEAMS: Sign and date appropriate sheet on first contact with patient and each day the patient is seen. 4. HEALTH CARE PROFESSIONALS: Place appropriate symbol in space provided: ie done not done or symbol provided and relevant. Place N/A in any box where the task is not applicable to the patient. Additional tasks due to patient individuality can be added to the pathway in OTHER boxes and/or Progress Notes. NOT ALL TASKS WILL APPLY TO EVERY PATIENT. 5. TRANSFER PATIENTS: If patient is transferred to another hospital in Grey- Bruce or to CCAC, send a copy of the following: m Discharge Criteria - original to stay on patient chart m MAR Sheet - original to stay on patient chart m Anticoagulant Record - original to stay on patient chart m Teaching Checklist - original to stay on patient chart m Caregiver Checklist - original to stay on patient chart Grey Bruce Health Network 1

2 NAME (Please Print) INITIAL SIGNATURE DESIGNATION (RN / RPN/ OTHER) All rights reserved. No part of this document may be reproduced or transmitted, in any form or by any means, without the prior permission of the copyright owner Grey Bruce Health Network 2

3 CLINICAL PATHWAY CHECHLIST EMERGENCY PHASE 0-3 HOURS P = Done O = Not Done N/A = Not Applicable * requires descriptive charting in progress notes INITIAL VITAL SIGNS + O 2 SATS *NOTIFY PHYSICIAN IF SBP > 220 OR DBP > 120 FOR 2 OR MORE READINGS 5-10 MIN APART **Immediate Notification of the Acute Stroke Multidisciplinary Team is recommended on admission** THOSE PATIENTS STAYING LONGER THAN 3 HOURS IN ER WILL HAVE ACUTE PHASE ACTIVATED CONTINUOUS CARDIAC MONITOR / RHYTHM STRIPS INTERPRETTED AND ATTACHED * DOES PATIENT HAVE KNOWLEDGE / DOCUMENTED HISTORY OF HAVING AN IRREGULAR HEART RATE / PREVIOUS? * RELEVENT / EMERGENT COMORBIDITIES DOCUMENTED DATE / TIME ER PHASE DATE / TIME ON TRANSFER ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) TREAT TEMPS >37.5 *NOTIFY PHYSICIAN FOR TEMP > 38.5 CHEST ASSESSMENT: C - Clear *A - Adverse sounds PAIN ASSESSMENT: SCORE 0-10 MONITOR FLUID INTAKE AND OUTPUT: V - Voided C - Catheter I - Incontinent URINE COLOUR: CATHETER TYPE AND SIZE: INITIAL ASSESSMENT NATIONAL INSTITUTES OF HEALTH SCALE (NIHSS) FLOW SHEET, then Q2H x 24 hours (Indicate Score) BLOOD WORK (Specifically CBC, APTT, INR, ELECTROLYTES, CREATININE, GLUCOSE) LABORATORY / DIAGNOSTICS CT SCAN ECG ER ADMISSION SIGNATURE: ER TRANSFER SIGNATURE: Grey Bruce Health Network 3

4 ` GREY BRUCE HEALTH NETWORK EMERGENCY PHASE 0-3 HOURS P = Done O = Not Done N/A = Not Applicable * requires descriptive charting in progress notes DATE / TIME ER PHASE DATE / TIME ON TRANSFER IV SITE ESTABLISHED / INSITU AND SATISFACTORY TREATMENTS/ INTERVENTIONS 2ND IV SITE ESTABLISHED / INSITU AND SATISFACTORY ISCHEMIC NON-THROMBOLYTIC / NON-HEMMORAGIC ONLY: ASA 160 mg MEDICATIONS ISCHEMIC THROMBOLYTIC THERAPY ONLY: ALTEPLASE BEST MEDICATION RECONCILIATION FORM COMPLETED AND SIGNED ACETAMINOPHEN FOR TEMPERATURE > 37.5 NUTRITION MOBILITY/ACTIVITY PSYCHOSOCIAL SUPPORT/ EDUCATION CONSULTS TRANSFER NPO BED REST PATIENT / FAMILY INFORMED OF DIAGNOSIS / REASON FOR ADMISSION ADVANCE DIRECTIVE DISCUSSION ADDRESSED ADDRESS IMMEDIATE CONCERNS CONFIRM ORDER FOR ACUTE MULTIDISCIPLINARY TEAM ENTERED IN CERNER AS: C - Confirmed stroke REPORT CALLED TO RECEIVING UNIT INDICATED TIME: INFECTION CONTROL SCREENING QUESTIONS REVIEWED FOR APPROPRIATE BED PLACEMENT ER ADMISSION SIGNATURE: ER TRANSFER SIGNATURE: Grey Bruce Health Network 4

5 National Institutes of Health Stroke Scale Flow Sheet Category 1a. Level of consciousness (LOC) 1b. LOC, questions (month, age) 1c. LOC, commands (open/close eyes, make fist, release) 2. Best gaze (patient follows examiner's finger) 3. Visual (introduce visual stimulus) 4. Facial palsy (show teeth, raise eyebrowns, squeeze eyes shut) 5a. Motor arm - Left (elevate arm to 90 and score drift/movement) 5b. Motor arm - Right (as above) 6a. Motor leg - Left (elevate leg to 30 and score drift/movement) 6b. Motor leg - Right (as above) 7. Limb ataxia (finger-nose, heel down shin) 8. Sensory (pin prick to face, arm, trunk, and leg - compare side to side) 9. Best language (name item, describe a picture and read sentences) 10. Dysarthria (evaluate speech clarity by patient read or repeat listed words) 11. Extinction and Inattention (use information from prior testing) Date Time Description Score Score Score Score 0 Alert - Alert 1 Drowsy - wakens with stimulation 2 Stuporou - (requires repeated stimuli) 3 Coma 0 Answers both correctly 1 Answers one correctly 2 Answers neither correctly 0 Performs both correctly 1 Performs one correctly 2 Performs neither correctly 0 Normal 1 Partial gaze palsy 2 Forced deviation 0 No visual loss 1 Partial hemianopia 2 Complete hemianopia 3 Bilateral hemianopia 0 Normal 1 Minor asymmetry 2 Partial paralysis (lower face) 3 Complete 0 No drift 1 Drift 2 Some effort against gravity 3 No effort against gravity 4 No movement X Amputation, joint fusion 0 No drift 1 Drift 2 Some effort against gravity 3 No effort against gravity 4 No voluntary movement X Amputation, joint fusion etc 0 Absent 1 Present in one limb 2 Present in two or more limbs X Amputation, joint fusion 0 Normal 1 Partial loss 2 Dense loss 0 No aphasia 1 Mild to moderate aphasia 2 Severe aphasia 3 Mute, global aphasia 0 Normal articulation 1 Mild to moderate slurring 2 Severe (near uninteligible or worse) X Intubated or other physicial barrier 0 No neglect 1 Partial neglect 2 Profound neglect TOTAL SCORE Initials of Examiner For Thrombolytic Strokes: NIHSS - Q2H x 24 hours, then twice per shift x 48 hours, then QSHIFT x 4 days For Non-Thrombolytic Strokes: NIHSS - Q6H x 72 hours or unless change in presentation 5 of 21

6 ACUTE CARE PHASE (Record QSHIFT on Checklist) P = Done O = Not Done N/A = Not Applicable * requires descriptive charting in progress notes DAY 1 DAY 2 DAY 3 PERFORMANCE INDICATORS 1 DYSPHAGIA SCREENING TOOL COMPLETED (Once Q24H) INITIALS: Pass / Fail keep NPO q Met q Not Met q N/A VITAL SIGNS + O 2 SATS: (Thrombolytic increased frequency as ordered) (Non-Thrombolytic - Day 1: Q4H Day 2: QID Day 3: QSHIFT * NOTIFY PHYSICIAN IF SBP > 220 OR DBP > 120 FOR 2 OR MORE READINGS 5-10 MIN APART X 48 HOURS RECORD REGULARITY OF HEART RATE (Note if patient aware of any past anomalies) REG - Regular / IRREG - Irregular TREAT TEMPS >37.5 * NOTIFY PHYSICIAN FOR TEMP > 38.5 CHEST ASSESSMENT Q4H: C - Clear * A - Adverse sounds ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) PAIN ASSESSMENT Q4H: CATHETER REMOVED: * I - Intervention SCORE 0-10 INTAKE AND OUTPUT QSHIFT (Nofity physician for < ml/h) V - Voided C - Catheter I - Incontinent HNV - Has Not Voided URINE COLOUR: BOWEL ROUTINE: C - Continent I - Involuntary O - Ostomy NATIONAL INSTITUTES OF HEALTH SCALE (NIHSS): Q2H x 24 hours, then twice per shift x 48 hours, then QSHIFT x 4 days MODIFIED RANKIN SCALE BRADEN (SKIN) RISK ASSESSMENT COMPLETED ON ADMISSION AND PRN (Indicate Score) (Indicate Score) PATIENT SAFETY CUE CARDS IN PLACE IN ROOM (no straws, acute stroke checklist, fall risk symbol, etc) MORSE FALL RISK ASSESSMENT COMPLETED ON ADMISSION AND PRN (Indicate Score) PATIENT SAFETY CUES * MORSE FALL RISK INTERVENTIONS DOCUMENTED * CONSENT OBTAINED FOR MINIMAL RESTRAINT FOR SAFETY AND REASSESSED Q24H RESTRAINT OBSERVATION Q MIN INITIALS: Grey Bruce Health Network 6

7 ACUTE CARE PHASE (Record Q4H on Checklist) P = Done O = Not Done N/A = Not Applicable * requires descriptive charting in progress notes DAY 1 DAY 2 DAY 3 LABORATORY / DIAGNOSTICS BLOOD WORK AS ORDERED: (Documenting procedure completed) SWABS MRSA & VRE COMPLETED ON ADMISSION THEN Q WEEKLY DIAGNOSTICS: ALTERNATE ROUTES DETERMINED FOR MEDS IF PATIENT NPO MEDICATIONS * ASSESS RISK / NEED FOR DVT PROPHYLAXIS WITH PHYSICIAN (Limited Mobiltiy / type of stroke significant in rationale for ordering) TREATMENTS/ INTERVENTIONS IV AND/OR INTERMITTENT SET OBSERVATION AND SITE CARE Q1H S - Satisfactory C - Changed R - Removed IF NON-AMBULATORY: S - anti-emboli Stockings or C - sequential Compression device DIET TEXTURE AS PER DYSPHAGIA SCREENING TOOL: (Diet order from physician only) NUTRITION F - Feed self A - Assist C - Complete feed (% of diet taken if not NPO) NG FEEDING ESTABLISHED / CLINICAL NUTRITION CONSULT PROTOCOL INITIATED / ENTER FEEDING ORDER SET INITIATED NON-THROMBOLYTIC - ACTIVITY AS TOLERATED THROMBOLYTIC - RESTRICTED AS ORDERED X 24 HOURS HEAD OF BED ELEVATED MINIMUM 30 DEGREES FOR NPO / TUBE FED PATIENTS MOBILITY / ACTIVITY * USE POSITIONING TO MAINTAIN PROPER BODY ALIGNMENT (SEE "TIPS AND TOOLS" BOOK FOR REFERENCE PURPOSES) SPECIAL EQUIPMENT: PERSONAL HYGIENE: C - Complete / Cueing required A - Assist S - Self SLEEP: R - Restless F - Fair W - Well INITIALS: Grey Bruce Health Network 7

8 ACUTE CARE PHASE (Record Q4H on Checklist) P = Done O = Not Done N/A = Not Applicable * requires descriptive charting in progress notes DAY 1 DAY 2 DAY 3 PSYCHOSOCIAL SUPPORT/ EDUCATION DISCHARGE PLANNING * ADDRESS PATIENT AND FAMILY ANXIETY IF APPLICABLE / * ENCOURAGE PATIENT AND FAMILY TO ASK QUESTIONS * BARRIERS TO LEARNING DOCUMENTED (Patient or Family) *SPECIFIC COMMUNICATIN / NEGLECT DEFICITS DOCUMENTED GIVE PATIENT PATHWAY TO PATIENT / FAMILY BEGIN / CONINUE TEACHING CHECKLIST WHEN APPROPRIATE (Patient/family have received "LET'S TALK ABOUT " book) ASSESS DISCHARGE CRITERIA DAILY - Assess readiness for rehabilitation using referral form - Complete Blaylock Discharge Planning Risk Assessment Screen - Fax referral to Community Stroke Team when discharged INITIALS: Progress Notes: Grey Bruce Health Network 8

9 ACUTE CARE PHASE MULTIDISCIPLINARY TEAM P = Individual Disciplines have reviewed and updates recorded accordingly UPDATE PATIENT STATUS IN CERNER AS CONFIRMED OR UNCONFIRMED TO ACTIVATE THE ACUTE MULTIDICIPLINARY TEAM P DATE & TIME SIGNATURE CONSULTS (To be completed by individual discipline and signed with signature) * PHYSIOTHERAPY * OCCUPATIONAL THERAPY * SPEECH/LANGUAGE PATHOLOGIST IF REQUIRED * CLINICAL NUTRITION * PHARMACIST * CCAC / DISCHARGE PLANNING * SOCIAL WORKER * Progress Notes: Grey Bruce Health Network 9

10 MODIFIED RANKIN SCALE q Admission date: q Discharge from Acute Care date: * This is to be completed on all Stroke as baseline (pre-treatment) and discharge from Acute Care* Please indicate who provided the information: q Patient q Family member q Patient s physician q Registered Nurse q Other: Specify GRADE DESCRIPTION QUESTIONS TO CONSIDER FOR GRADING Baseline Discharge q 0 q 0 No symptoms at all. No limitations. q 1 q 1 Does person have difficulty reading or writing, No significant disability speaking, problems with balance/coordination, despite symptoms; able to visual problems, numbness, loss of movement, carry out all usual duties and difficulty swallowing or other symptoms resulting activities. from stroke? q 2 q 2 q 3 q 3 q 4 q 4 q 5 q 5 Slight disability; unable to carry out all previous activities but able to look after own affairs without assistance. Moderate disability; requiring some help, but able to walk without assistance. Moderately severe disability; unable to walk without assistance, and unable to attend to own bodily needs without assistance. Severe disability; bedridden, incontinent, and requiring constant nursing care and attention. Has there been a change in person s ability to work or look after others if these were roles before stroke? Change in person s ability to participate in previous social and leisure activities? Problems with relationships or become isolated? Is assistance essential for preparing a simple meal, doing household chores, looking after money, shopping or traveling locally? Is assistance essential for eating, using the toilet, daily hygiene, or walking? Requires constant care. RN / MD Signature: / Baseline assessment Grey Bruce Health Network Discharge assessment 10

11 CLINICAL PATHWAY Braden Risk Assessment SCORING (Key on Reverse) DATE DATE DATE RISK FACTOR SCORE Sensory Perception: Ability to respond meaningfully to pressure related discomfort Completely Limited Very Limited Slightly Limited No Impairment Moisture: Degree to which skin is exposed to moisture Constantly Moist Often Moist Occasionally Moist Rarely Moist Activity: Degree of Physical Activity Bedfast Chair Fast Walks Occasionally Walks Frequently Mobility: Ability to change and control body position Completely Immobile Very Limited Slightly Limited No Limitations Nutrition: Usual food intake pattern Very Poor Probably Inadequate Adequate Excellent Friction and Sheer Problem Potential Problem No Apparent Problem TOTAL SCORE NURSE S INITIALS Nursing Intervention: Once you have assessed the patient and identified a risk category (high, moderate or low), carry out the following interventions for the patient's risk category. LOW RISK (SCORE > 15) Ongoing assessment for change in status related to any of the six risk areas Document reassessment weekly on Kardex MODERATE RISK (SCORE 13-14) Initiate and document plan of care on Kardex and Unit specific Progress Notes including: -Activity level (i.e. turning, positioning) -Continence management -Monitoring of pressure point areas -Monitor nutritional status -Skin care tools used: prevention mattresses or treatment (i.e. air mattresses), creams, bed hoop, trapeze, dressings -Patient education re: prevention Includes Moderate Risk Intervention plus requested referral to: -Physiotherapy -Occupational Therapy -Dietitian HIGH RISK (SCORE < 12) Grey Bruce Health Network 11

12 Braden Risk Assessment - page 2 RISK FACTOR Sensory Perception Ability to respond meaningfully to pressure related discomfort 1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level or consciousness or sedation. OR Limited ability to feel pain over most of body surface. 2. Very Limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. OR Has a sensory impairment, which limits the ability to feel pain or discomfort over 1/2 of body. SCORE/DESCRIPTION 3. Slightly Limited Responds to verbal commands but cannot always communicate discomfort or need to be turned. OR Has some sensory Impairment, which limits ability to feel pain or discomfort in 1 or 2 extremities. 4. No Impairment Responds to verbal commands. Has no sensory deficit, which would limit ability to feel or voice pain or discomfort. Moisture Degree to which skin is exposed to moisture Activity Degree of physical activity 1. Constantly Moist Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. 1. Bedfast Confined to a bed. 2. Often Moist Skin is often, but not always moist. Linen must be changed at least once a shift. 2. Chair Fast Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 3. Occasionally Moist Skin is occasionally moist, requiring an extra linen change approximately once a day. 3. Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair. 4. Rarely Moist Skin is usually dry, linen only requires changing at routine intervals. 4. Walks Frequently Walks outside the room at least twice a day and inside room at least once every two hours during waking hours. Mobility Ability to change and control body position Nutrition 1. Completely Immobile Does not make even slight changes in body or extremity position without assistance. 1. Very Poor Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement. OR Is on NPO and/or maintained on clear fluids or IV for more than 5 days. 2. Very Limited Makes occasional slight changes in body or extremity position, but unable to make frequent or significant changes independently. 2. Probably Inadequate Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR Receives less than optimum amount of liquid diet or tube feeding. 3. Slightly Limited Makes frequent, though slight changes in body or extremity position independently. 3. Adequate 4. Excellent Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally, will refuse a meal, but will usually take a supplement if offered. OR Is on a tube feeding or TPN (Total Parenteral Nutrition) regimen, which probably meets most of nutritional needs. 4. No Limitations Makes major and frequent changes in position without assistance. Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation. Friction and Shear 1. Problem Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction. 2. Potential Problem Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time, but occasionally slides down. 3. No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times Grey Bruce Health Network 12 Review Dec2016

13 TRANSITIONAL PHASE DAY: DAY: DAY: (Record Q4H on Checklist) P = Done O = Not Done N/A = Not Applicable * required descriptive charting in progress notes INITIAL DATE PERFORMANCE INDICATORS 2 3 INTERDISCIPLINARY CONSULTS COMPLETED TRIAGE (TRANSITION PLAN) COMPLETED q Met q Not Met q N/A q Met q Not Met q N/A VITAL SIGNS QSHIFT & PRN INCLUDING 0 2 SATS TREAT TEMPS >37.5 *NOTIFY PHYSICIAN FOR TEMP >38.5 CHEST ASSESSMENT QSHIFT & PRN C - Clear *A - Adverse sounds PAIN ASSESSMENT QID & PRN *N - Needs intervention Score 0-10 ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) SKIN INTEGRITY QSHIFT MONITOR BOWEL AND BLADDER ROUTINE C - Continent *N - Needs intervention I - Incontinent NATIONAL INSTITUTES OF HEALTH SCALE (NIHSS) QSHIFT FOR 4 DAYS REASSESS DYSPHAGIA SCREENING TOOL IF INDICATED P - Pass F - Fail BRADEN (SKIN) RISK ASSESSMENT UPDATED MODIFIED RANKIN SCALE IF PATIENT BEING DISCHARGED FROM ACUTE CARE (Indicate Score) PATIENT SAFETY CUE CARDS IN PLACE IN ROOM (no straws, acute stroke checklist, fall risk symbol) PATIENT SAFETY CUES (UPDATED - PRN) MORSE FALL RISK ASSESSMENT *I - Interventions required *CONSENT OBTAINED FOR MINIMAL RESTRAINT FOR SAFETY AND REASSESSED Q24H RESTRAINT OBSERVATION Q MINUTES LABORATORY / DIAGNOSTICS BLOOD WORK DIAGNOSTICS INITIALS: Grey Bruce Health Network 13

14 TRANSITIONAL PHASE (Record Q4H on Checklist) DAY: DAY: DAY: P = Done O = Not Done N/A = Not Applicable * required descriptive charting in progress notes MEDICATIONS ALL MEDICATIONS AND ROUTES ESTABLISHED REASSESS IV WHEN ORAL INTAKE >1500 ML IN 24 HOURS REMOVE/CHANGE IV SITE Q72H (INCLUDING TUBING) TREATMENTS/ INTERVENTIONS IF NON-ABULATORY BOWEL/BLADDER RETRAINING ONGOING S - anti emboli Stockings or C - sequential Compression device - PLAN DOCUMENTED AND *A - Adjustments made REMIND PHYSICIAN OF REMOVAL OF URINARY CATHETER REMOVAL DATE / TIME: (Recommended after fluid balance established) q DIET TEXTURE AS PER DYSPHAGIA SCREENING TOOL q REGULAR TEXTURE - HEALTHY HEART DIET q SPECIAL DIET: NUTRITION % OF DIET TAKEN IF NOT NPO IF TUBE FEEDING T - Tolerated *A - Adjustments as ordered CONTINUE METHOD OF PATIENT TRANSFER AND DOCUMENT IN PATIENT CARE PLAN (SEE "HEALTHY MOVES" BOOKLET FOR REFERENCE PURPOSES) MOBILITY/ACTIVITY USE POSITIONING TO MAINTAIN PROPER BODY ALIGNMENT (SEE "TIP AND TOOLS" BINDER FOR REFERENCE PURPOSES) DOCUMENT TOLERATED SITTING TIME DAILY REVIEW PATIENT-SPECIFIC RISK FACTORS FOR SECONDARY PREVENTION PSYCHOSOCIAL SUPPORT/ EDUCATION ADDRESS QUESTIONS REGARDING PATIENT PATHWAY AND/OR "LET'S TALK ABOUT " BOOKLET ENGAGE FAMILY IN CAREGIVING (Identify barriers and document for follow-up) ADDRESS ANY QUESTIONS, FEARS AND ANXIETIES THE PATIENT/FAMILY MAY HAVE INITIALS: Grey Bruce Health Network 14

15 TRANSITIONAL PHASE (Record Q4H on Checklist) P = Done O = Not Done N/A = Not Applicable * required descriptive charting in progress notes DAY: DAY: DAY: REHABILITATION CONSULT DISCUSSION INITIATED *BARRIERS TO REHABILITATION READINESS - Plan commenced to optimize readiness / alternate plan DISCHARGE PLANNING UPDATE AND REVIEW PLAN FOR DISCHARGE WITH PATIENT/CAREGIVER CAREGIVER TRAINING/EDUCATION CHECKLIST COMPLETED AND UNDERSTOOD BY CAREGIVER Progress Notes: REFERRAL TO CCAC DISCHARGE PLANNING INITIATED DATE / TIME: ASSESS DISCHARGE CRITERIA DAILY AND NOTIFY COMMUNITY TEAM WHEN PATIENT DISCHARGED INITIALS: Grey Bruce Health Network 15

16 TRANSITIONAL PHASE MULTIDISCIPLINARY TEAM P = Individual Disciplines have reviewed and updates recorded accordingly P DATE & TIME SIGNATURE *PHYSIOTHERAPY CONSULTS (To be completed by individual discipline and signed with signature) *OCCUPATIONAL THERAPY *SPEECH/LANGUAGE PATHOLOGIST IF REQUIRED *CLINICAL NUTRITION *PHARMACIST *CCAC / DISCHARGE PLANNING - assistive device needs identified and arranged - home program developed and discussed *SOCIAL WORKER * Progress Notes: Grey Bruce Health Network 16

17 MAINTENANCE PHASE BEYOND DAY 6 P = Done O = Not Done N/A = Not Applicable "O" requires descriptive charting in progress notes UPDATE THE PATIENT CARE PLAN ACCORDING TO THE FOLLOWING LISTED CRITERIA, THEN DISCONTINUE THE PATHWAY. CHARTING TO BE RESUMED ACCORDING TO UNIT CRITERIA. COMPLETED FOR LONGER TERM PATIENTS CONSIDER OBTAINING ALC ORDERS VITAL SIGNS ACCORDING TO UNIT PROTOCOL CHEST ASSESSMENT Q SHIFT ONLY IF DYSPHAGIC PAIN ASSESSMENT PRN ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) SKIN INTEGRITY Q SHIFT BRADEN RISK ASSESSMENT UPDATED MONITOR BOWEL AND BLADDER ROUTINE MODIFIED RANKIN SCALE IF PATIENT BEING DISCHARGED FROM ACUTE CARE REASSESS DYSPHAGIA SCREENING TOOL IF INDICATED PATIENT SAFETY CUES TREATMENTS/ INTERVENTIONS NUTRITION UPDATE PATIENT SAFETY CUES PRN MRSA AND VRE SWABS Q WEEKLY (Next date to be completed indicated on Care Plan) IF NON-AMBULATORY, ANTI AMBOLI STOCKINGS/SEQUENTIAL COMPRESSION DEVICES q DIET TEXTURE AS PER DYSPHAGIA SCREENING TOOL q REGULAR TEXTURE - HEALTHY HEART DIET q SPECIAL DIET: PUSH ORAL FLUIDS IF NOT NPO DOCUMENTATION FOR TUBE FEEDING AND FEEDING TYPE ACTIVITY AS TOLERATED REVIEWED DAILY MOBILITY/ACTIVITY TRANSFERS INDICATED ON CARE PLAN (SEE "HEALTHY MOVES" BOOKLET FOR REFERENCE PURPOSES) AMBULATION INDICATED ON KARDEX DOCUMENT TOLERATED SITTING TIME DAILY MULTIDICIPLINARY TEAM: RECOMMENDATIONS CLEARLY COMMUNICATED ON CARE PLAN INITIALS: Grey Bruce Health Network 17

18 PSYCHOSOCIAL SUPPORT/ EDUCATION MAINTENANCE PHASE BEYOND DAY 6 P = Done O = Not Done N/A = Not Applicable "O" requires descriptive charting in progress notes TEACHING ON GOING COMPLETED ASSESS DISCHARGE CRITERIA DAILY DISCHARGE PLANNING ONGOING STRATEGY TO OVERCOME BARRIERS TO DISCHARGE IN PLACE UPON PATIENT DISCHARGE, REFER TO PATHWAY DISCHARGE CRITERIA SHEET Progress Notes: INITIALS: Grey Bruce Health Network 18

19 DISCHARGE CRITERIA DATE MET INITIAL 4 DRIVING STATUS REVIEWED q Met q Not Met q N/A PERFORMANCE INDICATORS 5 SECONDARY PREVENTION RISK FACTORS ADDRESSED q Met q Not Met q N/A REFERRAL TO PREVENTION CLINIC COMPLETED ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) LABORATORY / DIAGNOSTICS SPEECH/LANGUAGE AND/OR SWALLOWING FOLLOW UP ARRANGED IF NEEDED SKIN INTEGRITY PLAN REQUISITION FOR OUTPATIENT BLOOD WORK GIVEN DISCHARE MEDICATIONS LIST EXPLAINED TO PATIENT AND FAMILY MEDICATIONS PATIENT / FAMILY INDICATE THEY UNDERSTAND MEDICATIONS PERSCRIPTION GIVEN TREATMENTS/ INTERVENTIONS NUTRITION MOBILITY/ACTIVITY BOWEL AND BLADDER ROUTINE ESTABLISHED NEED FOR COMMUNITY DIETITIAN REFERRAL IDENTIFIED DISCHARGE TRANSPORTATION ARRANGED PATIENT AWARE OF RISK FACTORS AND MANAGEMENT PSYCHOSOCIAL SUPPORT/ EDUCATION PATIENT AND FAMILY AWARE OF MANAGEMENT PLAN PATIENT AND FAMILY HAVE UNDERSTANDING OF EDUCATION CAREGIVER TRAINING/EDUCATION COMPLETED PATIENT AND FAMILY AWARE OF FOLLOW UP APPOINTMENT DISCHARGE PLANNING TRANSFER INFORMATION CHECKLIST COMPLETED CCAC DISCHARGE PLAN COMPLETED - ASSISTIVE DEVICES ARRANGED AND IN HOME FOLLOW UP OUTPATIENT THERAPY AS APPROPRIATE CONSULTS ALL CONSULTS COMPLETED - NOTIFY COMMUNITY TEAM OF DISCHARGE THROUGH REFERRAL Grey Bruce Health Network 19

20 Progress Notes: Grey Bruce Health Network 20

21 TRIAL SEPT 2, 2014 OCT 31, 2014 Affix Patient Label here PLEASE DOCUMENT TO THE HIGHEST LEVEL OF SPECIFICITY Type of Stroke ( check all that apply ) Ischemic / Cerebral Infarction Identify the cause and site i.e. embolism or thrombus and site of arteries (precerebral or cerebral etc.) Hemorrhagic Identify the artery from which bleed originated i.e. middle cerebral, basilar artery, anterior communicating artery etc. Intracerebral Identify the anatomical site of the bleed i.e. hemisphere, subcortical; hemisphere, cortical; brain stem etc. Deficits/Sequelae - related to current admission Hemiplegia Dominant side Non-dominant side Urinary retention Urinary/fecal incontinence Sensory Loss Neglect Speech/language deficits Aphasia/Dysphasia Dysarthria Apraxia Hemianopia None Other Co-morbidities: Diabetes Hypertension Smoking Obesity Dyslipidemia Other Interventions: CT MRI Ventilation Percutaneous endoscopic gastrostomy (PEG) Other Prescription for Antithrombotic medication at discharge Yes No Physician/NP Signature: Date: (Must be signed in order for Health Records to use for coding) 21