HOSPITAL NAME INSTITUTIONAL POLICY AND PROCEDURE (IPP) Department: Manual: Section: TITLE/DESCRIPTION INTERDISCIPLINARY ASSESSMENT AND REASSESSMENT OF PATIENTS POLICY NUMBER EFFECTIVE DATE REVIEW DUE REPLACES NUMBER NO. OF PAGES APPROVED BY APPLIES TO PURPOSE This is a policy that governs the assessment and reassessment of all patients admitted to the hospital. DEFINITION POMR: Problem Oriented Medical Record SOAP: Subjective, Objective, Assessment, Plan HHC: Home Health Care ADL: Activities of Daily Living RESPONSIBILITY CROSS REFERENCES POLICY The policy is further categorized to discipline specific assessment and reassessment. Time frames and criteria for reassessment must be adhered to according to the policy. Patients with the following special criteria shall receive an individualized assessment which are: 1) The very ill patient. 2) The frail and elderly patients. 3) Terminally ill patients 4) Drug and or alcohol dependency 5) Victims of abuse and neglect The information obtained from the initial assessment/reassessment will be utilized to develop a collaborative plan of care, which includes goals and action for pain relief, the presence, quality, and intensity of pain while utilizing the patient s selfreport as the primary indicator of pain. Patient s needs are prioritized based on assessment results. The patient and his/her family participate in the decisions about the priority needs to be met. PROCEDURE Standards Page 1 of 9
DISCIPLINE-SPECIFIC ASSESSMENT AND REASSESSMENT PROCEDURE/EXPLANATION 1. MEDICAL STAFF A. Initial Assessment: i. The initial assessment will be performed by a member of medical staff as defined in the medical bylaws. This will be recorded within 24 hours of admission and will follow the SOAP guidelines referenced in this policy II. The initial assessment of patients admitted for surgery or invasive procedures will be recorded prior to surgery and will include in addition to the previous criteria the preoperative diagnosis of the patient in addition to the results of relevant investigations and the anesthetic assessment. III. Patients requiring individualized assessment will be referred to the appropriate service. iv. Patient s referred from other institutions will have their referral criteria evaluated and discrepancy between current assessment and the previous one documented in the medical records. b. Reassessment: i. Reassessment will be completed at least once a day by member of medical staff and documented in medical records. ii. Reassessment will be performed whenever there is a change in the patient s condition, to document medication/procedure response, after return from surgery and upon transfer from another service or unit. iii. Reassessment of patient will include documentation of the patient s response to treatment and any suggested change in the plan of care. iv. Reassessment will follow the SOAP guidelines referenced in this policy 2. NURSING STAFF ASSESSMENT AND REASSESSMENT a. Initial Assessment: i. An initial nursing assessment of patient comprising of pulse, BP, temperature and respiration, and pain, is made on arrival and documented by SN1 or SN2. ii. A full assessment must be completed within 24 hours of admission to the hospital. iii. The assessment will include the following: 1. physical status 2. psychosocial status 3. nutritional status 4. functional status 5. discharge planning status 6. cultural needs iv. The nursing admission assessment will be completed comprehensively and every area of the nursing form will have a written entry v. Areas of assessment form that do not apply to the particular patient being assessed must be annotated not applicable vi. Problems and needs identified within the nursing assessment will be clearly linked to an Standards Page 2 of 9
individual plan of care that identifies: 1. actual/ potential problems 2. nursing interventions and rationale 3. anticipated outcomes 4. timeframe for evaluation of interventions vii. The nurse will include the patient and family in the care planning process whenever possible and this will be documented in the progress notes viii. Where applicable the nurse will generate referrals to other disciplines like nutritional needs, social and economic needs. Any other referrals that requires physician orders will then be relayed and submitted. ix. Nutritional assessments should be performed to identify which patients are at risks, to be further referred immediately by the nurse to a Clinical Dietician (see screening criteria for adults and pediatrics attached) x. Assessments of neonates, infants, children shall include; 1. developmental age, 2. length or height, 3. weight and head circumference as indicated by age and condition of the child 4. immunizations status 5. family expectations for and involvement in the care and treatment of the patient 6. pain management 7. emotional, financial, educational and social needs. 8. Assessments of patients who have behavioural disorders should have the following: emotional, mental and behavioural history treatment of mental disorders complete psychosocial assessment 9. Assessment of older adults will include the following: visual and hearing ability fall risk assessment sleep disturbance eating and feeding difficulties pain management skin breaks presence of pressure ulcers, and the need for restraints xi. Assessments of patients must include identification of educational needs of both patient and family, and readiness and ability to learn, with clear documentation in the progress notes, nursing assessment form, with a notation in the Interdisciplinary Patient/Family Education Record as to how these needs will be addressed. b. Reassessment i. All patients will be reassessed formally by the SN1 or SN2. Reassessment will be Standards Page 3 of 9
documented within the progress notes and will be at specific intervals related to care and indicated by the patient s condition. In any event frequency of reassessment will be no less than 12 hourly. ii. Patients will be reassessed pre and post operatively, on transfer and when there has been a change in functional abilities, treatment or change in diagnosis of the patient, or when there is a deterioration or improvement in condition iii. The plan of care will be amended to reflect any change in the condition of the patient following reassessment. iv. Decision on the frequency of reassessment may be determined by both physician s order and the nurse s professional judgment. c. NUTRITION SERVICES 1. A Clinical Dietitian will perform initial nutritional assessment within twenty-four (24) hours of receipt of referral. An in-depth assessment will include the following: Review of screening information Diet prior to admission, weight history History of nausea, vomiting and diarrhea Diagnosis, laboratory data, body weight BMI, growth percentiles (as available) Medications identified to have pertinent effects on nutritional status Adequacy of intake Nutritional goals Recommendations for nutritional interventions and expected outcome of nutritional intervention Data and calculations pertinent to the assessment and recommendations will be documented in the progress notes Nutritional services will receive referrals between 0800 hours to 1700 ours Saturday through Wednesday. ii. A Clinical Dietitian will be on-call from 1700 hours Wednesday to 1700 hours Friday. During this time frame the clinical Dietitian may be reached by the on-call pager. d. Reassessment Inpatients i. Reassessment of nutritional needs will be an ongoing process performed by a Clinical Dietitian to determine changes in patient s condition and response to nutrition intervention ii. Inpatients reassessment is to be performed with five (5) days of implementation of nutrition intervention. iii. Data gathered during the reassessment will be utilized for revision of intervention and/or discharge planning and documented in the progress notes by a Clinical Dietitian. e. REHABILITATION SERVICES i. In response to a referral by a qualified physician 1. Qualified Therapists will make all assessments and reassessments. The initial assessment will be completed within 24 hours of receipt of referral for inpatients, Standards Page 4 of 9
and as soon as possible for outpatients. 2. The format utilized is the SOAP format. 3. When indicated other information is gathered including: home assessment, social history, previous treatment/rehabilitation input and results of investigations/x-rays. 4. The assessment is individualized to ensure all populations are treated in an efficient, safe and appropriate manner, such as the paediatric, frail, elderly, terminally ill, and victims of abuse/neglect 5. the plan of care is documented, based on the initial assessment, including goals to achieve, therapy modality and the number of sessions needed. 6. Reassessment will be performed as necessary to: evaluate the progress or change in the patient s status to modify the plan of care accordingly or discontinue rehabilitation services. 7. Reassessment will be: conducted daily for inpatients or in response to a significant change in the patient s condition or if there is a change in the patient s diagnosis or to determine if the treatment has been successful and the patient can be discharged. 8. Chronic patients may be assessed once a week or monthly f. HOME HEALTH CARE (HHC) 1. The initial assessment will be conducted when a referral to the HHC Program is received. The patient will be assessed prior to hospital discharge to ensure the patient meets the HHC criteria. 2. The Nurse Manager/designee will perform this process within 24 hours of the time the referral was received, and the nurse telephones that a referral has been initiated and forwards a faxed copy. 3. The HHC Program accepts referrals for inpatients and outpatients in the Hospital, the Emergency Department, and patients of all age groups 4. Assessment includes the following: Past medical history Psychological history Present ADLs Neuro/emotional/behavioural status Medication regime Nutritional requirements and status Family dynamics and identification of a caregiver Standards Page 5 of 9
Social assessment Social worker s social and financial assessment 5. Occupational Therapist: assessment for equipment requirements 6. Proposed plan of care based upon assessment findings are developed and discussed with the patient/caregiver/family 7. The patient/family/caregiver must be involved in the admission process 8. Determine that the patient meets the acceptance criteria of the HHC Program 9. Discuss the referral and assessment findings with the HHC Physician and formulate a plan of care 10. The initial assessment will be document on the HHC Nursing Assessment Form 11. Acceptance into the HHC Program will be made after the patient has been visited and assessed out in the home setting ii. Reassessment 1. The comprehensive assessment is updated and reviewed by the HHC multidisciplinary team as often as the patient needs/requires/or medical condition changes 2. Every three months (90 days) 3. Where the plan of care is revised by the HHC Physician/nurse 4. On patient being placed on the Inactive List (max. 3 months) 5. On discharge 6. The patient will be reassessed by the SN1 and HHC Physician 7. The reassessment will be documented in the HHC nursing assessment form and the Physician record 8. When HHC services are no longer required, the Primary SN1 will complete the Discharge Summary 9. When a patient is discharged from the HHC Program the original file is sent to Medical Records. If the patient is a current patient of the HHC Program you will find --- Sex: Male HHC on the patient's sticker. g. DISCHARGE PLANNING i. All Patient s Assessment Reassessment data will be documented in the patient s file ii. Initial assessment iii. The need for discharge planning referral is made, based upon the following: 1. MRP Discharge Planning Assessment upon admission. 2. Initial assessment and the ongoing Nursing assessment Review of the hospital inpatient list in the daily morning Discharge Planning Team meeting 3. Identification of patient s needs Discharge Planning via multidisciplinary departmental weekly meetings in each Unit 4. The Discharge Planner evaluates patients and families on a consultation basis within seventy-two (72) hours of referral. iv. Initial assessments by Discharge Planner will include the following: Standards Page 6 of 9
1. Current condition 2. Mobility & level of consciousness 3. Review of medical records and eligibility. 4. Bio data 5. Family support condition 6. Social assessment including financial and home situation. v. Reassessments 1. The reassessment of the patient's discharge needs is an ongoing process performed by the multidisciplinary team throughout the patient's stay and includes information gathered from chart review, the health care team and the patient and family. 2. Discharge Planning needs, and required equipment or supplies are reassessed by the multidisciplinary team on a weekly basis or sooner as indicated by the patient's condition. 3. Any changes in the social or home situation are reassessed. 4. Data from reassessment is documented in the medical record. h. RESPIRATORY CARE SERVICES 1. A Respiratory Care Therapist will perform the initial assessment within four (4) hours of referral for the general wards and within thirty (30) minutes for ER and ICU patients. 2. The initial assessment will include, but not limited to the following: Sputum amount, colour and consistency Chest x-ray analysis and report Auscultation Patients work of breathing, and identify current and potential respiratory problems Examination heart rate, respiratory rate, blood pressure and temperature, chest drainage, if any Cardio-Respiratory medication support, sedation and relaxant 3. All respiratory care plans will be developed and agreed upon with a member of the medical staff before implementing. 4. For patients receiving intermittent therapies, a respiratory care plan will be initiated which will include respiratory diagnosis, cardiopulmonary system review, clinical diagnosis data and age specific consideration 5. The initial respiratory care assessment will be documented in the respiratory care therapy record ii. Reassessment 1. The patient will be reassessed by a Respiratory Care Therapist: To determine the response to treatment When there is a significant change in condition and/or diagnosis Reassessment of the ventilated care plan will be done every twelve (12) Standards Page 7 of 9
hours, or more frequently if the patient s condition warrants Modification of the respiratory care treatment plan based on re-assessment will be carried out according to plan and discussion with the medical staff, established protocol and communicated to a member of the medical staff i. SOCIAL SERVICES 1. The initial assessment from inpatients will be performed by a Supervisor, Social Worker I, and Social Worker II and recorded on the next working day of the patient s admission. In the case of suspected abuse, The Director of Social Services, and the Supervisor will solely interact with the case. 2. The initial assessment from the outpatients will be performed by a social worker as soon as the referral is received. The initial assessment will include as appropriate: Evaluation of patient and or family needs Availability of internal and external support systems Psycho-social assessment Social and financial assessment Assessment of family systems Plans to address identified needs/problems/recommendations 3. Initial assessment will be documented in the medical record ii. Reassessment 1. Reassessment will be: An ongoing process, performed as required by a Supervisor, Social Worker I and/or Social Worker II. Performed when there are changes in the patient s social or health status Performed when new referral is received and new service is required Documented in the medical record. j. PHARMACEUTICAL CARE SERVICES ii. The initial assessment performed for drug-related issues by the Clinical Pharmacist is based on the following: 1. Past History taken by the Admitting Team, however, when more information or clarification is necessary regarding medications history, allergies, any symptoms or adverse responses to medication, the clinical pharmacist will interview the patient and / or his/her family member 2. Current medications regimen 3. Laboratory Investigations such as, but not limited to, liver profile, biochemistry, culture & sensitivities, Complete Blood Count, anticoagulation profile and drug levels may be ordered by clinical pharmacist when needed 4. The initial assessment is performed within 48 hours from admission, excluding weekends, and recommendations are documented in the Progress Note when deemed necessary Standards Page 8 of 9
FORMS iii. Reassessment iv. A reassessment for drug-related issues by the Clinical Pharmacist is performed for: 1. The patient s response to therapy as evidenced by vital signs and laboratory values and changes in medications regimen 2. A follow-up on consultation, such as the following: Renal function (e.g., using blood urea nitrogen, serum creatinine and calculated creatinine clearance) in case of amino glycosides dosing consultations, Patients response, vital signs and culture & sensitivities in case of antimicrobial selection consultation, and Liver profile, daily intake and output, biochemistry, coagulation profile, pre-albumin, a 24-hour urine collection of Urea Nitrogen (UUN) and creatinine, Dextrostix and Complete Blood Count and Differential in case of TPN consultation. 9.2.2 Reassessments are performed twice weekly, and more frequently when indicated, such as daily assessments for TPN EQUIPMENT REFERENCES Joint Commission International Standard: AOP 1.3, 2.0, COP 17, 18, 19 Medical Staff Rules and Regulations/Bylaws APPROVAL: Prepared by Reviewed by Approved By Approved By Latest Revision Approved By Name Signature Date Standards Page 9 of 9