Snow What?

Care Planning

with SNOMED

INNOVATIONS ‘13

SpeakerSpeaker

Lisa Rabideau, RN, BS, CPAN

Clinical Informatics ManagerCVPH Medical Center

Lisa Rabideau has completed commercial bias disclosure forms and do not have any conflicts of interest.

Objectives

Define Care Planning Contrast current care planning

process to future requirements Demonstrate use of SNOMED-

CT terminology Describe the future of

Interdisciplinary Care Planning

It is the policy of Corexcel and IMNE to ensure fair

balance, independence, objectivity, and scientific rigor in

all programming.

In compliance with the American Nurses Credentialing

Center (ANCC) and the Accreditation Council for Pharmacy

Education (ACPE), it is the policy of Corexcel and IMNE

that faculty disclose all financial relationships with

commercial interests over the past 12 months.

Corexcel’s provider status through the ANCC and IMNE’s

provider status through the ACPE, are limited to

educational activities. Corexcel, IMNE, ANCC and ACPE do

not endorse commercial products.

Open on current site 1926 Total licensed beds: 409

313 Acute Care beds 34 Psychiatric/Mental Health beds

96 Skilled Nursing Beds 42 temporary

>2300 employees, 521 RNs, 32 ISS staff, 163

physicians Beautiful Midtown Plattsburgh,

NY

CVPH Medical Center

Nursing DocumentationIn the

Beginning… SOAP APIE PIE Focus Graphic flow

sheets

From one extreme to the other

More Recently…

Checkboxes Data Elements Charting by

Exception (CBE)

Need to Strike a Balance

Data elements for reporting Notes to tell the patient

story

Nursing Care Plans

Intended to be plan to provide care

Paper or Computerized NANDA, NIC, NOC, CCC,

PNDS Done because you have to Standardized - Individualized

According to the “Book” Read the nurse’s admission assessment/history

and the medication record Review the history, current diagnostic test results,

nurse’s notes for the last 48 hours, progress notes of providers and current consultation reports

Interview the patient and complete an assessment Read about the diagnosis Select the appropriate standardized care plan Select the nursing and collaborative diagnoses that

are appropriate Modify the desired outcomes so they are

measureable and realistic Select the nursing actions that are relevant

Ulrich, S. Canale, S. (2005) Nursing Care Planning Guides. Elsevier Saunders: St. Louis, MO.

What really happens:

Assessment generates standard problem

Nurse reviews problems and chooses plans

Plans are pre-set with nursing orders

Generally not customized At pre-determined interval, nurse

clicks “mark reviewed” on plan of care page

Generates a clinical note with no relevant content.

Takes up space Annoys providers

Influencing the Transition…

Meaningful Use Stage 1 The number of patients … who have at

least one entry (or an indication that no problems are known for the patient) recorded as structured data in their problem list.

ICD-9 or SNOMED-CT Threshold 80%

MU Stage 2 Part of Transitions of Care SNOMED-CT required Threshold 65% of Transitions of Care

electronically transmitted

Moving from Nursing Care Plans to Interdisciplinary Problem List/Plan of Care

Currently used by Nursing Consult orders go to other

services Documenting done primarily

in assessments, some on paper

Initial Step

Took list of existing Nursing Care Plan Problems

Found appropriate SNOMED problem

Re-mapped and re-named problems

Example of Crosswalk

Current Problems in Test

Current Problems in Prod

SNOMED options

Knowledge deficit of community resources

Special educational needs

Knowledge deficit of discharge planning

Knowledge deficit of discharge planning

Special educational needs

Knowledge deficit of smoking habit

Knowledge deficit of Smoking habit

Smoker

Knowledge deficit of therapeutic regimen-diabetes mellitus

Knowledge deficit of therapeutic regimen-diabetes mellitus

Special educational needs

Skin integrity impairment Skin integrity impairment Broken skin, tear of skin, pressure sore of (site), decubitus ulcer

Skin integrity impairment risk Skin integrity impairment risk

Infection Infection Infection, Infection due to resistant organism

Infection risk Infection risk Immunodeficiency disorder, nutritional deficiency, neutropenia etc

Problem Name MappingProblem SNOMED

Nutrition Deficit Risk Nutrition Impairment

Injury Risk Fall Risk

Fluid Volume Impairment Edema

Acute Pain Acute Pain

Infection Problem-Potential At Risk for Infection

Knowledge Deficit-Smoking Smoker-Current Smoker

Anxiety Anxiety

Skin Integrity Impairment Risk Risk for Impairment

Impairment Skin Integrity Actual Chronic Ulcer of the Skin

Activity Intolerance Risk Mobility Impairment

Breathing Pattern Impairment Respiratory Distress

Body Weight Impairment-Bariatric Obesity

Sleep Pattern Impairment Disturbance in Sleep Behavior

Knowledge DeficitTherapeutic Regimen- Diabetes

Diabetes Mellitus

Chest Pain Acute Chest Pain

Comfort Care Dying Process

Problems not in “Starter Set”

Entrapment Precautions Elopement Precautions Comfort Care, Dying Process

(added manually)

Restraints

Care Plan Orders

Met with sub-group of Nursing Documentation Team

Edited care plan orders to minimize duplication, redundancy

Reviewed existing plans 1 by 1

CPOE Order Sets

Contain Nursing Orders for appropriate problems.

Use of Nursing “Protocols” Drive “Problem Order” to

Plan of Care

Protocol ContentA. Assessment:1. Assess the location, radiation and duration of pain.2. Assess intensity of pain on scale of 0-10.3. Assess quality of pain (pressure, throb, heavy, burn, ache, sharp).4. Identify events leading to episode of pain.5. Assess EKG & telemetry strips for irregularities and ST changes.6. Monitor blood pressure, apical pulse.7. Monitor respiratory rate, character, and oxygen saturation.8. Monitor skin color and temperature, presence of diaphoresis.9. Monitor LOC (level of consciousness).B. Interventions:1. Provide oxygen to the patient during chest pain episodes and next

24 hours. Re-evaluate according to oxygen protocol.2. Assess the need for nitrates, antacids, and analgesics.3. Call for a STAT EKG to be done according to criteria outlined in

General Information.4. Implement patients coping strategies in reducing pain.5. Assess blood pressure after EKG if no relief of pain.6. Administer nitroglycerin per orders.7. Provide a calm environment. a. Turn lights to dim. b. Utilize patient support systems in reducing anxiety as

appropriate. c. Turn off television or any other excess noises.

Other Nursing Measures

Addressed in Order Sets Addressed in Standards of

Care

Comfort Care CPOE Order Set

Standards of Care

Use Marker Model of structure, process and outcome standards

Address nursing process (APIE), Basic needs (activity, nutrition, elimination, sleep, comfort), Safety and Health management (including education)

Move to Interdisciplinary Plan of Care Using plan of care display for

multidisciplinary rounds Start with Respiratory and

Discharge Planning Document clinical note from

Care Plan under pertinent section of care plan problem.

Clinicians have clearer “patient story”

EDIS & Provider Documentation

Problem list now populated with both nursing and medical problems

Sometimes the same Learning curve for nursing

and providers

Problems populated list Plans need to be selected if

appropriate

Open problem to see source In this case it is Primary

Complaint

When note charted from problem, problem name is attached to note

Problems Needing Care Plan Orders

Pneumonia Heart Failure DKA

Resources

AHIMA Workgroup. "Problem List Guidance in the EHR." Journal of AHIMA 82, no.9 (September 2011): 52-58.

CVPH Medical Center Community Service Plan September 2012

Dykes, P., DaDamio, R., Goldsmith, D., Kim, H., Saba, V. Leveraging Standards to Support Patient-Centric Interdisciplinary Plans of Care. AMIA Annual Symposium Proceedings 2011; 2011: 356–363.

Matney, S., Warren, J., Evans, J., Kim, T., Coenen, A., Auld, V. Development of the nursing problem list subset of SNOMED-CT. Journal of Biomedical Informatics. doi:10.1016/j.jbi.2011.12.003

Patient Services Standards of Care (2013), CVPH Medical Center, Plattsburgh, NY

Ulrich, S. Canale, S. (2005) Nursing Care Planning Guides. Elsevier Saunders: St. Louis, MO.

Soarian Clinical Solutions Track 2 Session # 11

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