MCM 16-038 Patient Care - Veterans Affairs



IOWA CITY DEPARTMENT OF VETERANS AFFAIRS (VA) HEALTH CARE SYSTEM Iowa City, IowaMedical Center MemorandumJuly 26, 2016Number16-038118PATIENT CAREPURPOSE. To define policy and procedures for the delivery of patient care by the interdisciplinary care team.2.POLICY. a.The Iowa City VA Health Care System (ICVAHCS) will provide an organized, coordinated, continuous, and comprehensive system of care for patients and their families. The scope of service provided by each department is defined in the Plan for the Provision of Services. Patients with the same health problems and care needs will receive the same level of care throughout the facility and community-based outpatient clinics (CBOCs). Patients requiring hospitalization will be provided the highest level of care in the unit most appropriate for their clinical condition, with procedures in place to ensure optimal care is uniformly and expediently delivered even when patients must be managed in temporary bed locations. If a patient needs a service not available at the ICVAHCS, then arrangements will be made to either transfer or refer the patient to the appropriate health care facility [Medical Center Memorandum (MCM)?59, InterFacility Transfer and Transport Services]. b.An interdisciplinary team of health care providers will develop a plan of care to meet the individualized needs of the patient. Patients and families/significant others are encouraged to participate in all aspects of the plan of care to foster optimal patient outcomes. The members of the team will vary depending on the patient’s condition, assessed needs, and care setting.c.The plan of care is dynamic in nature and is based on the patient’s diagnosis as determined through assessment/reassessment data, the patient’s desire for care/treatment, and the patient’s response to any previous care/treatment. The plan of care is initiated from data collected in the initial assessment process. The initial assessment data may, as appropriate, include but is not limited to eligibility status, medical history, current medications, nutritional status, pain status, psychosocial status, spiritual and cultural orientation, home environment and care factors, compliance issues, educational factors, self-care factors, and discharge planning needs and may be collected in either an inpatient or outpatient care setting.d.Data collected from the assessment process will be analyzed and discussed with the patient, and as appropriate, the patient’s family/significant other, to determine the appropriate plan of care. The patient and family/significant other will be provided sufficient information about the nature and goals of the care to assist them in making informed decisions about seeking care, care options, and availability and cost of such care. Based on the initial assessment and identified care needs, the patient is provided access to the appropriate level of care, health professional(s), and setting(s). The scope and intensity of any further assessment will be based on the patient’s diagnosis, care setting, desire for care/treatment, and response to any previous care/treatment. All the aforementioned will be incorporated into the plan of care. e.Patients will be reassessed by the interdisciplinary care team to determine response to treatment, evaluate progress toward goals, evaluate changes in condition/diagnosis, determine patient satisfaction with the level of progress achieved, and the cognitive and emotional adaptation of the patient and family to the patient’s health status. The patient’s interdisciplinary care team including but not limited to physicians, physician assistants, case managers, nurses, nurse practitioners, dietitians, physical therapists, occupational therapists, respiratory therapists, pharmacists, and social workers. Reassessments will be completed when the patient’s condition changes, as indicated by protocols, plans of care, or as requested by the patient, family, or health care provider. Information generated through the analysis of assessment/reassessment data is communicated among the team to identify and prioritize the patient's need for care through a coordinated, collaborative interdisciplinary approach. The plan of care is updated as the patient’s care needs and preferences change. The plan of care is documented in the patient’s medical record.f.Any tests, procedures, referrals, or consults requested through the assessment/reassessment process will be ordered according to the clinical indications of the patient and scheduled in a timely manner. Requests for consults or referrals will be completed and performed in accordance with MCM 40, Patient Services/Consults. Special program officials/coordinators are identified in Attachment A.RESPONSIBILITY. a.Hospital-based service chiefs and administrators are responsible for ensuring administrative and clinical compliance with this policy.b.Members of the medical staff are responsible for determining the degree of assessment and care provided to each patient presenting for care within their clinical privileges. The medical staff will write orders consistent with medical practice, MCMs, Medical Staff Bylaws, and Medical Staff Rules and Regulations and communicate to the appropriate team members the patient’s needs, based on their assessment findings.c.A Registered Nurse (RN) will be responsible for assessing inpatient nursing care needs. He/she is responsible for delegating and coordinating patient care for patient care programs, including supervision of Licensed Practical Nurses (LPNs), Nursing Assistants (NAs), Health Care Technicians (HCTs), and other ancillary providers. Functional statements, policies, standard operating procedures, and protocols identify the RN’s responsibilities and performance. d.Social work practice responsibilities are directed toward assisting Veterans to achieve their optimal level of health and coping. These professional practice responsibilities include: (1)Helping patients and families cope with the crisis of illness(2)Maximizing the social and interpersonal functioning of patients(3)Promoting vocational and social rehabilitation(4)Providing education to patients and interdisciplinary team members on the psychosocial impact of illness and disease progression(5)Facilitating the patients return to the community at the highest level of functioning possible(6)Working with terminally ill patients and bereaved families(7)Developing special approaches to provide solutions to unique social problems(8)Coordinating discharge planning, including providing information and referral services and accessing and coordinating community resources/services(9)Providing case management servicese.Clinical managers/supervisors are responsible for providing adequate staffing, ensuring the competency of their employees, and for the assessment and provision of the educational needs of their employees.f.Special program officials/coordinators are responsible for communicating and promoting their respective programs within the Iowa City VA Health Care System.g.Each employee’s particular responsibilities will be determined by his or her credentials, competence, and professional skills and by relevant licensure, certification, regulations, clinical privileges, scope of practice, and position description/functional statement.PROCEDURES. a.The ICVAHCS provides care to patients through four distinct care settings: Emergency Department (ED), outpatient specialty care, primary care, and inpatient care. The patient’s plan of care is developed as defined in the policy of this memorandum. The interdisciplinary care team in charge of the patient’s care may change over the continuum of care; however, communication and coordination regarding the plan of care will be maintained through all care settings. b.Patients appearing acutely ill should be screened without delay by a health care professional to determine the urgency of the care required. Based on the health care professional’s assessment and patient’s desire for care/treatment, the patient should be referred to the most appropriate care setting. Patients requiring emergent care/treatment will not be detained for administrative details. c.Care Settings(1)Emergency Department (ED)(a)The ED provides emergent care to patients with conditions deemed urgent or emergent. (b)Patients without an appointment (i.e., walk-ins) should be directed to the ED. In ED, a triage nurse will assess the patient and determine the acuity level of his/her problem. The ED Triage Nurse will coordinate efforts to ensure the patient is seen in the appropriate care setting in an appropriate time frame. After seeing the ED Triage Nurse, the patient will be directed to the clerical staff in the appropriate care setting to complete the necessary administrative details.(c)Inappropriate referrals to ED include any chronic problems (i.e., low back pain for several months). Chronic problems/conditions should be handled by the clinic (specialty or primary care) seeing the patient. The patient should not be sent to ED unless the problem is emergent and cannot be handled in the clinic. The patient should not be sent to the ED unless they need emergent care not available immediately on the inpatient ward and should not be sent to the ED waiting room pending inpatient room availability.(d)Appropriate referrals to ED include but are not limited to: unstable cardiac dysrhythmias, severe pain with acute onset, uncontrolled hypertension, minor trauma, seizures, respiratory distress, infectious illness with potential for serious acute symptoms, shock/hypotension, poisoning, bleeding, dehydration needing the administration of intravenous fluids, and psychiatric emergency. External referrals from outside facilities for inpatient admission will only be permitted if the triage treatment plan has been discussed between the admission treatment team and the ED providers.(e)All patients will have an electronic progress note completed by the triage nurse at the time of their assessment. This assessment note will include the acuity level and services identified as minimally necessary for the individual patient. The assigned provider will also complete an electronic progress note within the timeframes set by ICVAHCS policy. An acute treatment room flow sheet will be completed by the nursing staff.(2)Outpatient Specialty Care (a)Outpatient specialty care is comprised of a multitude of medical, surgical, and psychiatry specialty and subspecialty clinics. (b)Access to specialty care is by consult/referral only. Consults/referrals for specialty care are defined in MCM 40, Patient Services/Consults.(c)All documentation (i.e., progress notes, flow sheets, screening forms) should be completed in a timely manner and in compliance with the time frames set by the ICVAHCS policy. (3)Primary Care (a)Primary care is the provision of health care services by a designated team of health care professionals who are accountable for addressing a large majority of personal health care needs, and in doing so, developing a sustained partnership with their patients. Primary care consists of intake, initial assessment, health promotion, disease prevention, management of acute and chronic conditions, referrals for specialty care, rehabilitation, other levels of care, followup, overall care management, and patient and caregiver education. Primary care consists of the general internal medicine teams (Primary Care Clinic teams and CBOC teams) and the subspecialty teams (Spinal Cord Injury/Dysfunction, Geriatrics, and Medicine/Psychiatry). (b)All patients being referred to subspecialty for Primary Care require a consult prior to being seen for their initial visit. Information required on the consult includes age, brief medical history, and reason for consult.(c)An initial Primary Care appointment will be scheduled in the Veterans Integrated Systems Technical Architecture (VistA) program within 30 days of request. At that time, the patient is assigned to a primary care team through the Primary Care Management Module (PCMM). Team assignment is based on the patient’s current health needs. Primary care team assignment is either to a general internal medicine team or to one of the subspecialty primary care teams.(d)At the initial visit, the patient will receive a complete history and physical, a health promotion and disease prevention evaluation, and an orientation to the primary care team. Topics discussed in the orientation include, but are not limited to, how to access the assigned primary care team, the shared medication policy, telephone triage, ED, pharmacy, and specialty clinics.(e)Based on the initial assessment data, the patient and primary care team will determine a plan of care. (f)The assigned primary care team is responsible for coordination among the health professionals from whom, and settings in which, the patient receives care or services. Referral, transfer, and discharge of the patient to another level of care, health care professional, or setting is based upon the patient’s assessed needs and desires. Determination of the facilities ability to provide the care or treatment is the responsibility of the assigned primary care team.(g)Documentation guidelines are outlined in Attachment B (4)Inpatient Care(a)Inpatient care is available in medical, surgical, and psychiatry settings.(b)The admitting provider determines the need for admission based upon the assessment data and standardized criteria as approved by VHA. During non-administrative working hours, the decision for admission may come from the designated admitting provider. (c)Patients may be referred from local providers or other hospitals for admission. The VA Telephone Operator will forward the outside facility to the Utilization Management (UM) nurse or (Administrative Officer of the Day (AOD) during non-administrative hours), this is not a recorded call. UM will triage the call to determine which service (Med/Surg/Psych) should review case, request clinical records be faxed to appropriate VA provider for review and notify appropriate VA provider of referral. After clinical records are received and reviewed by VA provider, UM (AOD) will notify VA Telephone operator to set up a recorded call with the local provider, VA?provider, AOD, Nursing Supervisor/UM. Eligibility & Enrollment/AOD will determine eligibility for care in the VA system. The provider will be responsible for telephone consultation with the referring provider to determine the patient’s stability for transfer, and whether the patient will be seen for examination or accepted for admission to this facility.(d)The following bed choices are available at the ICVAHCS:(1)Forty eight (48) hour observation (Attachment C)(2)Admission (Attachment D)(e)A perpetual bed inventory, for bed availability, will be maintained in VistA of all patient admissions, discharges, deaths, observation status, and inter-ward transfers. (f)If no beds are available, the admitting provider will determine if the need for hospitalization is emergent, urgent, or general. Processes are in place to find an appropriate bed in-house, within the VA system, or in the community (Attachment?E).(g)If the individual requiring admission is ineligible for inpatient care and non-emergent, he/she will be referred to a local hospital where care can be provided. If the individual requires emergent care and cannot be safely transported to another facility, he/she will be admitted until the condition permits safe transfer to another facility.(h)An interdisciplinary plan of care will be implemented at entry into the facility and continued throughout the hospitalization. This plan of care will serve as a basis for continuity and consistency of care and for discharge planning. Assessment and documentation requirements are outlined in Attachment I. (i)The procedure for storing a patient’s personal belongings while admitted is addressed in Attachment F.(j)The need for discharge planning will be determined as part of the assessment. Discharge planning will be initiated on admission and incorporated in the plan of care. The interdisciplinary team members will plan and coordinate with the patient/family for the attainment of treatment goals and transition to home and/or appropriate care settings (i.e., rehabilitation facility).(k)Interdisciplinary discharge rounds will be completed by each patient care team minimally twice weekly and will include a review of the patient’s anticipated length of stay, identify variable or potential barriers to discharge, review the needs identified on the Admission Assessment: Patient Database form, review for patient/family education needs, screen for ethical issues related to care delivery, and integrate the findings and action plan into the patient’s plan of care. (l)Upon discharge, the patient’s plan of care will be communicated to the appropriate health care providers (i.e., primary care team). 5.REFERENCES. a.VA Manual M-1, Part 1, Chapters 5, 8, 13, 14, 16 and 17;b.VHA Directive 2007-01298-023, Guidance for the Implementation of Primary Care in VHA; c.VHA?Directive 2007-012, Eligibility Verification Process for VA Health Care Benefits;d. VHA Handbook 1101.02 Primary Care Management Module (PCMM); e.VHA Directive 1009, Standards for Addressing the Needs of Patients Held in Temporary Bed Locations; f.Joint Commission Accreditation Manual for Hospitals, current edition;f.Medical Staff Rules and Regulations;g.MCM 040 Patient Services/Consults;h.MCM 073 Health Information Management and Patient Health Records;i.MCM 049 Veteran Health Education and Prevention Policy; j.MCM 128 Workload Capture and Close Out of Patient Data Files;k.MCM 030 Treatment Abatement;l.Guidance for the Oversight and Supervision of Social Work Practice and Documentation, current publication;m.VHA Handbook 1110.02 Social Work Professional Practice;n.VHA Handbook 5338.4 Social Work Qualification Standards Including Licensure and /or Certification Requiremento.NASW Code of Ethics;p.VHA Directive 1036, Standards for Observation in VA Medical Facilities;q.MCM 166 Patient Medications Brought From Home;r.MCM 106 Reconciling Medications Across the Health Care System;s. MCM 048 Utilization Management Program6.RESCISSIONS. Medical Center Memorandum 14-38, Patient Care dated April 28, 2014./s/HEATH J. STRECK, MBAActing DirectorAttachments:A.Special Emphasis Program OfficialsB.Primary Care DocumentationC.Processing Applicants for ObservationD.Processing Applicants for AdmissionE.Bed ControlF.Inpatient Personal BelongingsG.Absences/PassesH.Inpatient DocumentationI.Documentation Standards for Social WorkSPECIAL EMPHASIS PROGRAM OFFICIALS/COORDINATORSCommunity Nursing Home (CNH) ProgramCNH Program Coordinator319-430-1561Compensation & PensionComp & Pen Managerext. 6267Electrophysiology Procedure CoordinatorCardiology Clerkext. 4801Environmental Registry Coordinatorext. 6267Heart/Lung Transplant CoordinatorTransplant Coordinatorext. 7931Homeless Program CoordinatorCedar Rapids: 319-365-0898; Rock Island: 309-786-1614Kidney Transplant Coordinatorext. 4780POW Coordinator319-330-1840PCT Coordinator688-3334Radiation Therapy Coordinatorext. 6290Spinal Cord InjurySCI Coordinatorext. 6055VIS ProgramVIST Coordinatorext. 6889 Utilization Management ProgramExt. 6226; 6227; 6229 6230; VA Pager 734Women Veterans CoordinatorWomen’s Health Social Workerext. 3591PRIMARY CARE DOCUMENTATIONAll documentation (i.e., progress notes, flow sheets, screening forms) should be completed in a timely manner and in accordance with time frames set in ICVAHCS policy. Please refer to MCM 73, Patient Health Record for specific guidelines related to documentation requirements and etiquette of electronic documentation.1.Nursinga.At each visit, vital signs, including screening for pain, will be recorded in the electronic medical record.b.Health Promotion and Disease Prevention Assessment is initiated at the first visit and updated/reviewed at each subsequent visit. Documentation is by electronic progress note and by use of clinical reminders.2.Physician and Physician Extendersa.An initial history and physical will be completed at the first visit by the primary care physician or physician extender. Documentation is by electronic progress note.b.Subsequent history and physicals will be repeated per standard of care.3.Primary Care Teama.The plan of care is developed from the assessment data gathered from the initial history and physical and from the Health Promotion and Disease Prevention Assessment. Documentation is by electronic progress note. Consults for specialty care will be generated according to hospital policy. b.A listing of all current medications, allergies, operative and invasive procedures, and significant active diagnosis/conditions will be initiated and maintained thereafter. The listing is located in the electronic record on the GUI cover page.PROCESSING APPLICANTS FOR OBSERVATION 1.PROCEDURES: Patients held in observation status must meet observation criteria and length of stay must be 47 hours, 59 minutes or less. An observation patient is a patient with a medical condition with a degree of instability or disability and who needs to be monitored, evaluated, and assessed for either admission to inpatient status or assignment to care in another setting or discharged home. Established criteria must be met prior to the patient leaving observation status.a.An observation patient can occupy any bed in any ward of the hospital, as determined appropriate to their clinical needs. b.Patients admitted to observation status are considered outpatients. UM will assist the provider in determining appropriateness of admission and admission status (observation versus acute) according to VHA approved criteria. UM can be contacted on pager 734, ext 6226, 6227, 6229, or 6230. UM decisions are final.Appeals regarding decisions can be addressed to the appropriate utilization physician advisor. (1)Patients are admitted to and followed by the inpatient service, based on team capacity in consultation with specialty services as warranted by their condition. This service/specialty has responsibility for the patient’s treatment and disposition. Assignment and admission of the observation patient to a designated service/specialty allows for the tracking of patients and the ability to utilize specific software. (2)The appropriate team will determine the care of the patient based on admitting diagnosis. The team will also determine the disposition of the patient at the end of the 47 hours, 59 minute time frame.c.A provider’s order that reads “Admit to Observation Status” must be written for referral to an observation bed. d.Patients in observation status will be accurately identified and tracked on the Gains and Losses Sheet (G&L). e.In order to provide a consistent mechanism to initiate allotted time frame for observation status admissions, the observation status time will begin at the entry of the admission order into the computer. f.Documentation for a patient placed in observation will be as follows:(1)Initial Assessment and History and Physicals are to be completed within eight hours with subsequent notes documented as the patient’s condition warrants.(2)Admission note indicates the reason for observation, a working diagnosis, a treatment plan, and a clear definition of the endpoint for patient disposition.(3)RN assessment and health history completed within four hours of admission. (4)Discharge order, diagnosis and note on discharge.g.The medical record will be designated as “Observation Bed” by the Medical Support Assistant/AOD.h.Patients admitted to observation status will be provided access to all ancillary services available to acute admissions. One level of care is offered to all patients.i.Patients who are kept in observation status longer than 47 hours, 59 minutes and don’t have an order to discharge to home or admit to acute will be considered inappropriate observation stays. The provider will be required to discharge the patient from observation and admit to acute care status. Existing orders can be copied and pasted to new admission. The provider must write a progress note that identifies the patient was admitted to acute status due to specific changes in condition. A new history and physical is not required. New medication and other orders must be entered.PROCESSING APPLICANTS FOR ADMISSION1.PROCEDURES: The decision to admit a patient is based on the identified patient needs, the type of treatment required, and the patient’s desire for care.a.The admission process begins when a VA provider who has examined the patient determines the need for admission. The patient will be classified as either observation, critical, acute or behavioral health.b.If a specialty consult is required to determine the need for admission, it should be obtained promptly. c.Providers requesting a patient admission Monday through Friday, 7:00 am to 5:30 pm should contact Utilization Management (UM). UM will assist the provider in determining appropriateness of admission and admission status (observation versus acute) according to VHA approved criteria. UM can be contacted on pager 734, ext 6226, 6227, 6229, or 6230. UM decisions are final. Appeals regarding decisions can be addressed to the appropriate utilization physician advisor. d.The provider will complete a Physician’s Order for admission. No patient will be admitted without a physician’s order.e.If the patient is stable, the patient will be sent to Eligibility & Enrollment for processing. If the patient is unstable, the patient will be escorted directly to the ward via appropriate transportation. Patients will be accompanied by appropriate escort until the handoff is complete. For direct admission to the ward from clinic, a call should be placed to UM/Nursing Supervisor for bed assignment.(1)UM will assist the provider in determining appropriateness of admission and admission status (observation versus acute) according to VHA approved criteria. UM is available Monday through Friday, 7:00 am to 5:30 pm and can be contacted on pager 734, ext 6226, 6227, 6229, or 6230. UM decisions are final. Appeals regarding decisions can be addressed to the appropriate utilization physician advisor. (2)UM/Nursing Supervisor notifies appropriate inpatient charge nurse on the floor receiving the admission.(3)UM/Nursing Supervisor will assign the bed in the Bed Management System (BMS).(4)UM/Nursing Supervisor calls report to nursing staff on the receiving floor.f.Patients may be referred from local providers or facilities for admission. The VA Telephone Operator will forward referrals to UM (M-F 0700-1730) or Nurse Supervisor, during non-administrative hours, to initiate the transfer process. UM can be contacted on pager 734, ext 6226, 6227, 6229, or 6230. The Telephone Operator will also inform the AOD of any admission requests forwarded to the Nurse Supervisor. (1)The outside facility must call to inform the operator they have a patient requesting transfer to the VA. (2)The operator will forward the outside facility to the UM nurse (Nurse Supervisor during non administrative hours).? This is not a recorded call.? UM/Nurse Supervisor will triage the call to determine which service should review the case. (3)UM will assist the provider in determining appropriateness of admission and admission status (observation versus acute) according to VHA approved criteria. UM decisions are final. Appeals regarding decisions can be addressed to the appropriate utilization physician advisor. (4)UM (Nurse Supervisor or AOD during non administrative hours) will ask for written records be faxed to the provider for review and provide the appropriate fax number. (5)Eligibility & Enrollment or the AOD will determine eligibility for the admission. If patient eligibility cannot be determined then applicable forms will be faxed to the patient before the patient can be accepted. (6)If an appropriate bed is not available, the UM office (Nurse Supervisor during non administrative hours) will inform the outside facility and provide other options/alternatives.(7)After information is reviewed by Hospitalist/SOD/POD, a call back is made to the outside provider to inform him/her if the patient is to be accepted for admission, accepted for evaluation in the ED, denied, or if further information is required.? This is a recorded call.(8)If the patient is accepted for admission, the outside facility is responsible for arranging transport of the patient to the IC VAHCS. All transfer patients must arrive via ambulance or secure car for psychiatry patients. In certain instances where both doctors agree patient safety is not a concern, patient may arrive by personal vehicle. In these instances, the patient must first report to the ED upon arrival to determine patient’s condition has not changed during transport and admission to the floor remains appropriate. (9)If the patient is denied, the outside facility will be informed of the reason for denial.(10)If a patient is accepted for evaluation, the outside facility will arrange transport to the ICVAHCS where the accepting provider will evaluate the patient.? In these cases, we request someone come with the patient in case admission is not necessary so he/she can get home. (11)If further information is required, the VA provider will discuss what further tests are required to ensure stability with the outside provider before the VA can accept transfer. (12)The procedure for transfers of surgery patients is similar with a few significant differences.? The surgery service chief has not mandated review of faxed information but this is encouraged. The SOD will review the information provided by the outside facility and consult with specialty service staff as needed. If the SOD accepts a patient to be evaluated in the ED, then the SOD must evaluate that patient upon his/her arrival. (13)The VA Telephone Operator will record all admission calls, informing all parties on the call this is being done.? The recordings will be transcribed on an as-needed basis.? Compact disks can be made of recorded calls and will be retained in a locked cabinet in the Telephone Office for 18 months after the date of the admission call.? When admission calls are transcribed, the transcriptions will be scanned in the patient’s administrative record.(14)The AOD will prepare a Report of Contact (ROC) for each admission call, recording all significant facts from the call.? This ROC will be scanned in the patient’s administrative record. g.Upon admission, the ward team members will check the computer for pending appointments and notify the treatment team. The attending physician will determine whether pending appointments will be accomplished during the hospitalization or cancelled and rescheduled. The ward clerk will reschedule appointments or arrange for the patient to attend the appointments based on the provider’s instructions.BED CONTROL1.Patient at IC VAHCSa.Admitting provider contacts Utilization Management (UM) M-F, 7:00?am to 5:30pm or Nurse Supervisor, during non-administrative hours. UM will assist the provider in determining appropriateness of admission and admission status (observation versus acute) according to established criteria. UM will then connect the admitting provider to the inpatient team on call for provider report. UM remains on call to provide both providers location of ward for admission and need for nursing report to be called prior to transfer. UM then notifies the assigned wards charge nurse of admission. Psychiatry admissions do not go through the Medical Officer of the Day (MOD).(1)UM can be contacted on pager?734. UM decisions are final. Appeals regarding decisions can be addressed to the appropriate physician advisor. UM contacts (charge nurse):(a) 7E Extension 6120, pager 668(b) 7W Extension 6100, pager 772(c)5W Extension 6170(d)ICU Extension 5360(e)9W Extension 5409(2)If beds are full and a patient at our facility requires hospitalization, the admitting provider must document in the medical record whether the need for admission is urgent, emergent, or general.(3)If the need is emergent, an attempt will be made to find a bed in-house. If a bed is not available, he/she will be transferred/admitted to the University of Iowa Hospitals and Clinics (UIHC) or an outside hospital at VA expense as approved by the Chief of Staff or designee.(4)If the need is urgent, an attempt will be made to find a bed in-house. If the patient can travel, he/she should be referred for transfer/admission at another VA facility.(5)If the need is general, the patient should be referred for transfer/admission to another VA facility. (6)In the event a non-critical patient requires admission and the inpatient bed is not readily available, the patient may be held in the Emergency Department (ED) for up to four hours after the decision to admit the patient is made. If the inpatient bed is not available within four hours, the patient will be observed in a temporary bed location/boarder status in the ED. Examples of beds not being readily available include: pending discharge, room being cleaned, etc.(7)The patient will be admitted to a virtual inpatient status and care will be transferred to staff on the inpatient team. The patient will be re-assessed according to the reassessment guidelines and upholding the standard of care for a patient admitted to an inpatient area.(8)The IC VAHCS has the capacity to care for up to two boarders in the ED at one time. Boarder patients will be provided food, medication, and other elements of comprehensive patient care services as appropriate. (9)If the patient is placed in a temporary bed/boarder status in the ED, he/she will be the next patient admitted to the facility, unless a critical patient arrives to the hospital requiring admission.b.UM calls ward charge nurse for bed availability status. During non-administrative tours, the Nursing Supervisor will assist the provider in determining appropriateness of admission and admission status according to established criteria. (1)UM or Nursing Supervisor will relay the following information to the ward charge nurse to include but not limited to the patient’s name, SSN, diagnosis, and care team.c.UM notifies Medical Support Assistant during business hours and MOD notifies AOD during off-hours.(1)UM or Nursing Supervisor will assist providers in locating an appropriate bed if there are no in-house beds. d.Medical Support Assistant/AOD prepares for patient arrival by making arm band, etc.e.Medical Support Assistant/AOD, upon patient arrival will enter patient information into VistA as an admission.2.Transfer Patient a.Outside referring provider contacts UM/AOD regarding the request for transfer, in turn they will notify the appropriate service (Hospitalist/SOD/POD) regarding patient transfer request. If the Hospitalist/SOD/POD cannot accept patient due to bed availability, UM/AOD will refer them to another VA facility.b.If questions arise about the VA payment for local treatment, the caller will be referred to the Care in the Community Department’s Case Manager for Emergency Treatment and Hospitalization (Phone 319-358-5996). c.UM notifies Non-VA Care during business hours and ROD/SOD/POD notifies AOD during off-hours.d.If patient is accepted for transfer by Hospitalist/SOD/POD to the VA, Patient Registration/AOD prepares for patient arrival by making an arm band, etc. e.Medical Support Assistant/AOD, upon patient arrival will enter patient information into VistA as an admission.INPATIENT PERSONAL BELONGINGS1.Valuables will be accepted for safekeeping, but the ICVAHCS will not assume responsibility for the loss of valuables remaining in the possession of patients. Patients will NOT be permitted to have the following items in their possession: Firearms, ammunition, or weapons of any type; illicit drugs; medicines; intoxicating beverages; any other article determined to be inappropriate by the facility Director.a.Upon admission, nursing staff will inform the patient and/or significant other of the policy and procedure for storage of personal belongings, including funds. Patients being admitted to the Acute Inpatient Mental Health Unit a. For patients being admitted to the Acute Inpatient Mental Health Unit, please refer to Mental Health Service Line Policy 15-001. (1)Patients will be encouraged to send home any items not needed during hospitalization. Nursing staff will document inventory on “Patient Belongings Checklist,” VAOP 002-46, indicating items brought with the patient to the hospital and disposition of those items kept at bedside, sent home with family, or sent to clothing room.(2)Upon discharge the form used to complete the initial inventory upon admission is also used to inventory at discharge.b.Clothing will be picked up by the clothing room employee for storage in the Patient Clothing Room. The clothing for patients on the acute mental health unit will be kept in the clothing room on the unit .c.Funds will be given to the Agent Cashier/AOD/Charge Nurse. Field Service Receipt, VA Form 4-1028, will be issued to the patient by the Agent Cashier. Temporary Receipt for Funds, VA?Form?102815, will be issued by all other VA employees accepting personal funds for patients. After hours funds for patients in the Emergency Department will be processed by AOD. After hours patients located on an inpatient floor will be processed by the Charge Nurse or delegate. All funds collected after hours will be placed in the safe located in 1W36.d.Medications – The patient will surrender all medications brought from home. The nursing staff will send the medication home with a family member or follow procedures outlined in MCM 166, Patient Medications Brought from Home.e.A patient clearance form issued by ward personnel will authorize the release of all deposited valuables, clothing, and effects. Signature of the patient or responsible representative and date will be obtained on Valuable Inventory Envelope, VA?Form?102637, when release is made. No itemized record will be maintained on clothing and effects whether in storage or upon release. Items not available at time of discharge will be shipped at VA expense in accordance with VA Regulation 4806. Disposition of VA Form 10-2637 will be made in accordance with VHA Record Control Schedule 10-1.f.Patient or representative will be notified if personal effects and/or valuables are left at the ICVAHCS. If a reply is not received within 90 days, the items will be sold or otherwise disposed of as determined by the facility Director or designee. ABSENCES/PASSESa.Providers cannot request an authorized absence or pass for acute care patients. Providers are to discharge or patients can leave Against Medical Advice (AMA). Acute Care areas include Medicine, Surgery and Mental Health.INPATIENT DOCUMENTATIONRefer to MCM 73, Patient Health Record, for specific guidelines related to documentation requirements and etiquette of electronic documentation.1.Physiciana.A complete and current History and Physical (H & P), including diagnosis and treatment plan, will be written within 24 hours of the patient’s admission. H & P completed 30 days prior to admission must be updated within 24 hours of admission to reflect changes in the patient’s condition. The provider must document an appropriate assessment confirming the necessity of the admission and any changes that have occurred. The date of the previous H&P should be documented in the initial inpatient note.b.Initial medication reconciliation will be documented within the first 12 hours of admission or transfer to another level of care. Medication reconciliation will also be completed at discharge and documented in the patient record. c.Patients need a complete and current H&P prior to undergoing any operative procedure. The H & P must have been completed within the last 30 days and must be updated prior to the procedure d.Patients will also have a standard medical record and discharge summary completed prior to discharge. Discharge Summary should include:(1)Reason for hospitalization(2)Procedure performed(3)Care and treatment provided(4)Patient condition at discharge(5)Information provided to patient and family at dischargee.All clinical services are responsible for identifying those patients who require discharge planning, participation in timely discharge planning for the patient and documenting that planning. f.Physician Service and section chiefs are responsible for ensuring attendance by assigned interns, residents or other providers at all discharge planning meetings for their team, providing direction regarding policies and procedures, and demonstrating the facility’s philosophy of discharge planning through their practices in patient care.g.VA Staff Physicians and Affiliated House staff Physicians are responsible for ensuring the patient’s right to have and participate in quality discharge planning and using the interdisciplinary discharge planning process for early identification of referral of problems to appropriate disciplines to facilitate discharge planning. The attending physician on the team is responsible for establishing the discharge date, if not otherwise designated by the discharge planning teams. This should be accomplished as early in the hospitalization process as possible to avoid acute care occupancy by patients ready for discharge from the hospital.h.Outpatients having an invasive procedure or ambulatory surgery will have an H & P within 30?days of the procedure. H & P must be updated prior to procedure. Those procedures conducted under local anesthesia only do not require an H & P exam.i.Patient will be reassessed and a progress note written at least every 24 hours.2.Nursinga.Flow sheets will be used where available. All other documentation will be done electronically.b.Within one (1) hour of admission, a RN will assess the patient.c.Within twenty-four (24) hours of admission or one (1) hour from checking into the ambulatory preadmission clinic, the Admission Assessment: Patient Database (VAOP 481) will be completed. d.A RN will initiate an individualized Nursing Plan of Care within 24 hours of admission.e.The Initial Nursing Assessment data base completed at admission will trigger consults to services such as social work, nutrition and food, and Chaplain for further assessment of patients who meet high risk criteria. Nurses assess the patient’s continuing care needs, coordinate care to meet patient outcomes, and collaborate with all disciplines in order to complete the discharge planning in a timely fashion.f.In the Emergency Department (ED) the initial focus assessment (triage) will be completed within ten (10) minutes of patient’s arrival to the ED.g.A re-assessment is indicated by patient condition, but at least every 30 minutes. If condition is stable and patient’s needs are met, depending on length of stay, reassess at least every two (2) hours.h.Reassessment of patients is a continuous process occurring with every patient/nurse encounter and/or change in patient condition or acuity. Content may, as appropriate, include but is not limited to vital signs, systems review, response to medication, mobility, appetite, condition of skin, wound healing, need/readiness for education, response to education, behavior, mental alertness. i.A nursing staff member will document at least every eight (8) hours for each non-intensive care patient and at least every four (4) hours for each intensive care patient. As the patient changes acuity, coordination and documentation will reflect the changes. Exception: Palliative Care patients will have a progress note documented at least every 24 hours regardless of acuity level. j.ICU: Reassessment of patient is documented on the “Critical Care Flow sheet.”k.The initial triage assessment will identify patient’s needs.l.Pertinent areas based on patient individual needs, diagnosis, significant change in condition or diagnosis, change in physician orders, and to determine response to treatment/nursing intervention.3.LPNs/NAS/HCTs/SNTsa.Nonprofessional staff conducts a variety of functions and support tasks, which may include the collection and reporting of physiological data (i.e., vital signs, weights, collection and measurement of inputs and outputs, admission data, EKGs, specimen collections, etc.) 4.Social Workersa.Social Workers are available for social problems, consultation, and discharge planning to the patient and their families to enable them to cope with the impact of illness and to achieve maximum benefits from the health care systems. Referrals may include, but are not limited to, the patients being unable to function independently and the living situation does not meet the patient’s needs including homelessness; the patient exhibits behavior that may interfere with maximum utilization of treatment; the patient indicates financial distress; the patient’s living/social situation is unclear and needs assessment; the patient needs post-discharge follow up; patient is identified at risk for a psychosocial crisis.b.The Social Work intervention will be initiated on all referrals/consults within three working days of receiving consult. Referrals are received verbally or by electronic consults. c.All Social Workers are responsible for Advance Directive education .d.Social Workers carry the primary responsibility for coordination of discharge planning for all Veterans who require nursing home and other placements. Discharge planning starts on day one of admission. They manage the psychosocial elements of patient care, including assisting with adjustment to the effects of the illness on the Veterans and family/significant others. Social workers, through their assessment, evaluate inpatients identified as requiring home health service to determine if living situation is adequate to meet the patient’s limitations and initiate the referral when it is appropriate. Priorities and patients’ needs for discharge planning are reviewed with the inpatient teams.e.Social workers work towards cooperative, supportive, discharge planning with Veterans and their families/significant others in collaboration with other disciplines, community resources and agencies. Timeliness is an inherent principal of the discharge planning activities of social workers.f.The Social Worker will reassess patients based on the problem identified, the treatment plan, and patient’s response to treatment. An assessment must be completed on all patients in order to identify their social work needs. Documentation will be by electronic progress note or consult note.g.Each social worker is responsible for entering a progress note to document his/her direct care of the patient. h.Every Veteran will be educated on Advance Directives. The discussion will be documented on either the Advance Directive Discussion or Advance Directive note.munity Health/ Contract Nursing Homea.Consults will be acted on prior to patient discharge by community health for referrals for patients to HBPC, Home Health Services, Hospice Services, Home Infusion, Contract Adult Day Health Care, and Homemaker/Home Health Aide Services when appropriate. Community Health provides continuity of care and monitoring of referrals made following discharge to assure patient needs are met.b.Contract Nursing Home Program approves and provides oversight of nursing home care for those Veterans who are eligible or who require nursing home care at VA expense.6.Dietitiansa.Nutritional assessment will be completed on all patients determined to be at nutritional risk. The initial screen is completed by a RN to identify patients at risk nutritionally with an electronic consult sent to the Registered Dietitian (RD) if nutritional care is needed. All inpatients will be assessed within 48 hours of receiving consult. Documentation will be by either a progress note or consult note.b.Nutrition and Food Services coordinates the patients’ in-house nutritional care which acts as a model plan prior to discharge; works with other team members, the patient and significant others to evaluate the Veteran’s nutritional status; and counsel’s patient and family as appropriate. c.The Nutrition Support Team is an interdisciplinary team that provides specialized nutritional care for those patients requiring parenteral or enteral feedings.d.The dietitian will reassess the patient based upon the patient’s response to treatment and any change in medical condition, which could alter the patient’s nutritional status. Documentation will be in the progress note or the consult note.7.Physical/Occupational Therapya.The initial screen is completed by a RN to identify patients with possible need for a functional assessment. The provider is notified electronically of those patients with a positive initial screen by nursing. If the need for a functional assessment is also identified by the provider, then a PT/OT consult is generated by the provider. A physical/occupational therapist will perform an evaluation within 48 hours of obtaining a consult (or sooner based on acuity of patient needs and discussion with referring team). The evaluation will include, as appropriate, an assessment of prior level of functioning, social support, home environment, patient and family goals, pain, functional status, mental status, learning/religious/cultural barriers, rehab potential, rehab goals, and rehab plan of care. Documentation is by electronic consult or progress note.b.Assesses post discharge rehabilitation needs and develops appropriate plan. Provides patient education as needed. Participates in discharge planning at the ward level as appropriate.c.The patient’s progress as related to the treatment plan is documented by electronic progress note with each therapy visit. d.Reassessment is done by a physical/occupational therapist every seven (7) days or when there is a change in the patient’s medical status. 8.Medical Support Assistantsa.Medical Support Assistants are responsible for initiating and maintaining the medical record as well as closure of the individual record upon discharge of the patient. b.They are responsible for patients to be administratively ready for discharge. They coordinate such items as appointments, prescriptions, travel arrangements, and prosthetics. They are responsible for processing the discharge orders and all administrative aspects of the patients discharge.9.Pharmacy Servicea.Pharmacy Service provides prescribed items in a timely manner for patient discharge. They coordinate patient’s medication needs with provider and nursing staff. Medication reconciliation services will be provided in accordance with MCM 106. DOCUMENTATION STANDARDS FOR SOCIAL WORKa.Each visit or direct contact with the patient, or on his/her behalf, is to be documented in the medical record as a progress note through the Computerized Patient Record System (CPRS).b.Each social worker is responsible for entering a progress note to document his/her direct care of the patient. The scope and intensity or comprehensiveness of the interaction/assessment are to vary depending upon; the complexity of the services provided; the patient’s diagnosis; the patient’s desire for assistance; and the patient’s response to prior intervention. All progress notes will be signed and dated with signature title attached. The social worker will also complete encounter/Event Capture information related to the visit. Telephone contacts are to be recorded in CPRS and entered as a telephone encounter. Errors in the electronic progress note will be corrected by attaching an addendum containing the corrected information and contacting HIMS. All approved documentation for social work interns will be co-signed by the field supervisor.prehensive social work documentation and treatment are an integral part of the total treatment and rehabilitation of each patient. A comprehensive assessment must be completed on all patients seen to ensure their psycho social needs are addressed. Scope and intensity of social work documentation, treatment, case management, and discharge planning activities will be based on diagnosis, care setting/level of care, the patient’s desire for care and the patient’s response to previous care received. Treatment, case management, the need for referrals, and discharge planning will be coordinated with other disciplines and documented as part of the patient’s clinical record. Patients will be reassessed at regular intervals in relation to the patient’s course of treatment, the patient’s response to treatment, or any significant change occurring in the patient’s psychosocial situation. Documentation will follow ICVAHCS and Joint Commission standards.(1)Social work progress notes:??Social work interactions that are significant (requiring a comprehensive assessment, care management or on-going intervention) will be annotated with the following in the CPRS progress note:(a)Identification of the problem: each Social Work note should identify the problem being addressed, with sufficient detail about the patient’s situation to put the problem into context.(b)Assessment of the problem: Each Social Work note should include the social worker’s assessment of the problem and situation, including the patient’s response to the problem.(c) Plan: The note should include a plan for addressing the problem. The psychosocial treatment plan should be coordinated with the patient and family members and with the interdisciplinary treatment team.(d) Outcome: Notes should contain information on outcomes to interventions and outcomes to attempts to resolve problems and address needs.(e) Signature with credentials and date: Social workers must sign and date each note, including their credentials (MSW, etc).d.Social work telephone or brief contacts:??Contact with a social worker that is brief or is done via telephone should not be held to the standard for in-depth patient care documentation. Documentation for brief patient/family and/or telephone contacts will include:(1)Statement of the problem(2)Intervention(3)Plan and outcomee.Social work consultations:??The social worker will respond to all consultation requests via CPRS. Consultations will be answered following ICVAHCS standards. f.Specific documentation:??In general, recording will include a psychosocial assessment, treatment plan/goals, social work interventions, ongoing progress, and outcome in relation to the goals or discharge planning. ................
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