Inpatient Rehabilitation, Home Health & Hospice ...



Case Conference Note ExamplesThe Encompass SOP has specific guidance regarding documenting the CC note. The first point to remember is that the case manager is responsible for documenting the case conference note that is thorough and collaborative. Only one case conference note for the patient being conferenced is necessary.Consider this guidance when documenting your case conference note and note a few examples that satisfy the basic criteria of a well-documented case conference note:Documentation Guidance: Patient/caregiver goalBriefly describe the patient or caregivers goal hereThis is captured at SOC and should be updated each episodeThis ensures the plan of care is always Patient-CenteredBody Structure/Function ImpairmentsList the body structure and body function problems as of todayThis will guide the development of the plan of care for the next episode and focus the care teamActivity LimitationsList the activity limitations (mobility, safety, ADLs, IADLs, self-care, etc.)This will guide the development of the plan of care for the next episode and focus the care teamEvidence of improvement/declineBriefly describe the patient’s progress, stabilization, or declineBarriers to improvementBriefly describe barriers to improvement (environmental, socioeconomic, medical, personal, etc.)f. ?? PlanBriefly describe what the patient will be recertified forIdentify disciplines to be involved in the new episodeExamplePATIENT / CAREGIVER GOAL: TO BE ABLE TO BATHE INDEPENDENTLY BODY STRUCTURE/FUNCTION IMPAIRMENTS: INTEGUMENTARY SYSTEM: STAGE 2 PRESSURE ULCER TO R BUTTOCK APROX 60% HEALED, ENDOCRINE: UNSTABLE BLOOD GLUCOSE WITH BLOOD SUGAR RANGES BETWEEN 720-240; MUSCULOSKELETAL: WEAKNESS TO UPPER EXTREMITIES AND POOR BALANCEACTIVITY LIMITATIONS: WALKER REQUIRED. ASSISTANCE NEEDED FOR AMBULATION AND TO SAFELY ACCESS THE BATHROOM. BATHING ASSIST REQUIRED DUE TO LIMITED MOBILITY AND TO KEEP WOUND DRY WHILE IN SHOWER. EVIDENCE OF IMPROVEMENT / DECLINE: PT UNABLE TO RECOGNIZE SIGNS OF HIGH OR LOW BLOOD SUGARS, WOUNDS REMAINS WITHOUT SIGNS OR SYMPTOMS OF INFECTION BUT HAVE BEEN SLOW TO HEAL DUE TO PT'S UNSTABLE BLOOD SUGAR LEVEL. PATIENT ABLE TO GET INTO BATHROOM CONSISTENTLY WITH WALKER AND MINIMAL ASSIST BUT IS UNABLE TO MANAGE KEEPING WOUND DRESSING DRY/INTACT DURING BATHING PROCESS DUE TO LIMITED UPPER EXTREMITY ROM. BARRIERS TO IMPROVEMENT: LEGALLY BLIND, ALONE PRIMARILY DURING THE DAY LIMITING CAREGIVER AVAILABILITY, KNOWLEDGE DEFICIT OF DIABETIS MANAGEMENT, INADEQUATE WOUND HEALINGPLAN: RECERT FOR FOCUSED EDUCATION ON DIABETIS MANAGEMENT, WOUND MANAGEMENT AND HEALING, MOBILITY AND SAFETY TRAINING TO IMPROVE BATHROOM MOBILITY. SN TO RECERT FOR 3W3, 2W1, 1W5. OT TO RECERT FOR 2W2, 1W3.Example PATIENT / CAREGIVER GOAL: I WANT MY ULCERS TO HEAL SO MY LEGS WON’T HURT SO MUCHBODY STRUCTURE/FUNCTION IMPAIRMENTS: INTEGUMENTARY SYSTEM – UNHEALED VENUS STATIS ULCERS BILATERAL LE; SENSORY IMPAIRMENT – PAIN IN BILATERAL LE DUE TO ULCER; VASCULAR IMPAIRMENT – DECREASED CIRCULATION TO BILATERAL LE WITH EDEMA NOTED; ENVIRONMENTAL - CLUTTER IN HOMEACTIVITY LIMITATIONS: PATIENT CURRENTLY ABLE TO SAFELY TRANSFER FROM CHAIR TO WHEELCHAIR TO BSC. NON AMBULATORY EXCEPT FOR DISTANCES OF LESS THAN 25 FEET.EVIDENCE OF IMPROVEMENT / DECLINE: LEG WOUNDS SHOW IMPROVEMENT NO LONGER NEEDING DRESSINGS APPLIED. SKIN REMAINS DR, INTACT BUT RED AND SCALY. PATIENT ABLE TO SELF MONITOR AND REPORT CHANGES IN LE TO NURSE APPROPRIATELYBARRIERS TO IMPROVEMENT: LACKS INSIGHT OR MOTIVATION TO ADDRESS ENVIRONMENTAL ISSUES - CLUTTER IN THE HOME POTENTIALLY CAUSING FURTHER INJURY TO LE WITH WHEELCHAIR PROPULSION. BILATERAL LE PAIN ALSO A BARRIER TO CONTINUED MOBILITYPLAN: SN TO RECERTIFY TO CONTINUE TO ASSESS, TREAT AND EDUCATE PATIENT REGARDING LE WOUNDS 1W4 WITH ANTICIPATED DISCHARGE AT WEEK 5 IF PATIENT'S CONDITION REMAINS STABLE. WILL ALSO REVIEW THE HOME FAST ENVIRONMENTAL ASSESSMENT AND ENGAGE THE PATIENT TO ADDRESS POTENTIALLY HARMFUL ENVIRONMENTAL BARRIERS IN THE HOME.Example PATIENT / CAREGIVER GOAL: TO BE ABLE GET AROUND WELL ENOUGH WITHOUT DEVICE AND RETURN TO MY OWN HOMEBODY STRUCTURE/FUNCTION IMPAIRMENTS: CARDIAC – UNSTABLE BLOOD PRESSURE AND AFIB; MUSCULOSKELETAL - WEAKNESS TO BILATERAL LE AND IMPAIRED RESPIRATORY FUNCTIONS - DECREASED ENDURANCE; IMPAIRED INTEGUMENTARY SYSTEM – EDEMA, BRUISING TO BILATERAL LE ACTIVITY LIMITATIONS: PATIENT CONTINUES TO PRESENT WITH WEAKNESS BLE'S AND HE REQUIRES SBA FOR AMBULATION WITHOUT DEVICE THROUGHOUT THE COMMUNITY. DECREASED BALANCE AS EVIDENCED BY A TUG SCORE OF 24 SECONDS ALTHOUGH IMPROVED FROM INITIAL MEASUREMENT OF 38 SECONDS. DECREASED ENDURANCE. PATIENT REPORTS DYSPNEA WITH ACTIVITY IN THE EVENINGS EACH DAY. UNSTABLE EDEMA IMPACTING FUNCTION.EVIDENCE OF IMPROVEMENT / DECLINE: PT HAS DEMONSTRATED GOOD PROGRESS REGARDING INCREASED INDEPENDENCE WITH MOBILITY, IMPROVED BALANCE AND IMPROVED COMPLAINTS OF DYSPNEA WITH ACTIVITY TO INCLUDE MEAL PREP AND BATHING WITH DYSPNEA REPORTED AS 3-4 COMPARED TO 6-7 AT SOC. PATIENT WILL BENEFIT FROM CONTINUED SKILLED PHYSICAL THERAPY TO MAXIMIZE SAFETY AND INDEPENDENCE WITH ALL FUNCTIONAL MOBILITY. PATIENT ABLE TO RECOGNIZE LOWER EXTREMITY EDEMA CHANGES WITH PROMPTS.BARRIERS TO IMPROVEMENT: NONEPLAN: RECERT PHYSICAL THERAPY FOR 2W4, 1W4 FOR CONTINUED STRENGTH, BALANCE AND ENDURANCE TRAINING. RECERTIFY FOR NURSING FOR EDUCATION RELATED TO NEW MEDICATIONS AND TEACHING OF SYMPTOM MANAGEMENT.Example PATIENT / CAREGIVER GOAL: “I WISH I HAD MORE ENERGY”BODY STRUCTURE/FUNCTION IMPAIRMENTS: EARS/EYES – HOH AND POOR VISION; MUSCULOSKELETAL – WEAKNESS WITH AMBULATION, POST OP ORIF; INTEGUMENTARY – BILATERAL LE PITTING EDEMA PRESENT. SURGICAL INCISION – HEALING. DIGESTIVE IMPAIRMENT – LOSS OF 20 POUNDS IN PAST FEW MONTHS. MENTAL FUNCTIONS – EMOTIONAL FUNCTIONS WITH DEPRESSION NOTED AS PATIENT UNABLE TO CONTINUE IN THE PRIMARY PROVIDER ROLE TO HER SPOUSE WITH DEMENTIA.ACTIVITY LIMITATIONS: UNABLE TO SAFELY AMBULATE IN HOME WITH WALKER. PATIENT HAS FAMILY SUPPORT IN THE NEIGHBORHOOD WILLING AND ABLE. CLUTTERED HOME WITH PETS THAT NEED TO BE TAKEN CARE OF.EVIDENCE OF IMPROVEMENT / DECLINE: PATIENT HAS PROGRESSED FROM ESSENTIALLY NON-AMBULATORY TO BEING ABLE TO AMBULATE. IMPROVEMENT NOTED IN WALKING SPEED AND TUG SCORE. PAIN WELL MANAGED. APPETITE IMPROVED SINCE SOC.BARRIERS TO IMPROVEMENT: 2 RECENT NEAR FALLS, PATIENT VERY COMPROMISED AT INITIAL EVALUATION AND REMAINS AT RISK FOR FALLS AND FUNCTIONAL DECLINE AND RISK ASSOCIATED WITH POOR MOBILITY WITHOUT INTERVENTION.PLAN: NURSING TO CONTINUE WITH MANAGING UNSTABLE INR 1W4. PHYSICAL THERAPY TO CONTINUE 2W3, 1W3 FOR STRENGTH TRAINING, PROGRESSING HEP, MOBILITY AND HOME SAFETY INSTRUCTION UTLIZING WALKER SAFELY AND INDEPENDENTLY. EDUCATION TO SON AND DAUGHTER IN LAW IN THE NEIGHBORHOOD REGARDING SAFETY NEEDS/MODIFICATIONS.Example PATIENT / CAREGIVER GOAL: I WANT TO QUIT COUGHING SO MUCH AND HEAL ALL OF THESE SKIN TEARSBODY STRUCTURE/FUNCTION IMPAIRMENTS: INTEGUMENTARY – IMPAIRED SKIN HEALING WITH FRAGILE SKIN; RESPIRATORY IMPAIREMENT WITH DECREASED ENDURANCE AND CONTINUED RESPIRATORY SYMPTOMS, ACTIVITY LIMITATIONS: POOR SAFETY AWARENESS WITH DECREASED SAFETY AT HOME, SELF MANAGEMENT OF HEALTH CONDITIONS TO INCLUDE MANAGING HEALING OF SKIN TEARS; MEDICATION MANAGEMENT IMPAIRMENT WITH INABILITY TO PROACTIVELY RECOGNIZE WHEN INHALER USE APPROPRIATE. EVIDENCE OF IMPROVEMENT / DECLINE: LACERATION TO RIGHT GREAT TOE IMPROVING, SKIN TEAR HEALED. UPPER RESPIRATORY SYMPTOMS ARE IMPROVING WHEN MEDICATION ARE UTILIZED APPROPRIATELYBARRIERS TO IMPROVEMENT: PATIENT UNABLE TO SELF MANAGE UPPER RESPIRATORY SYMPTOMS; PATIENT SLOWER TO LEARN AND APPLY KNOWLEDGE REGARDING SELF MANAGEMENT OF RESPIRATORY SYMPTOMS. PLAN: RECERT SN 3W2, 2W4, 1W2 FOR RESPIRATORY ASSESSMENT AND TEACHING TO PATIENT AND IDENTIFIED CAREGIVER, WOUND CARE AND PATIENT/CG EDUCATION TO RECOGNIZE RISK BEHAVIORS CONTRIBUTING TO SKIN TEARS.Example PATIENT / CAREGIVER GOAL: I WANT TO STOP GETTING UTIS AND MY WOUNDS TO HEAL PRESSURE ULCERS TO HEAL WITHOUT COMPLICATIONS, STABLE CP STATUS--EARLY DETECTION OF HF, DVT. MAINTAIN GU STATUS-PREVENTION OF UTIS, MAINTAIN FOLEY CATH PATENCY ALF MANAGES CATH CARE,?BODY STRUCTURE/FUNCTION IMPAIRMENTS: GENITOURINARY – RECURRENT UTIS, FOLEY PRESENT; INTEGUMENTARY – PRESSURE ULCERS ON BILATERAL ELBOWS, MULTIPLE SKIN TEARS; CARIOPULMONARY IMPAIRMENTS - RECURRENT HF EXACERBATION W RECURRENT PLEURAL EFFUSIONS; IMPAIRED EMOTIOINAL FUNCTIONS – REPORTING SYMPTOMS OF DEPRESSION; MUSCULOSKELETAL – DECREASED STRENGTH OVERALLACTIVITY LIMITATIONS: MOD ASSIST WITH TRANSFERS DUE TO POOR BALANCE AND DECREASED LE STRENGTH, W/C CONFINED WITH LIMITIED AMBULATION. FOLEY CATH REQUIRES ONGOING CATH CARE AND MONTHLY CATH CHANGES, ONGOING EDUCATION REQUIRED TO CAREGIVERS IN ALF. EDEMA BILATERALLY.EVIDENCE OF IMPROVEMENT / DECLINE: NEW TRAUMATIC SKIN TEARS APPEARING TO OCCUR DURING THE OVERNIGHT HOURS, FRAGILE COMPROMISED SKIN AT RISK FOR SKIN TEARS. PATIENT UNABLE TO IDENTIFY SYMPTOMS OF HEART FAILURE EXACERBATION BEFORE PROBLEMATIC. CAREGIVERS ARE REPORTING INCREASED EDEMA AND BREATHLESSNESS WITHOUT PROMPTS DURING WEEKLY MEETINGS. ALF EVENING STAFF AGREE TO BE PRESENT FOR TRANSFER TRAINING TO IDENTIFY RISK BEHAVIORS CONTRIBUTING TO SKIN TEARS.BARRIERS TO IMPROVEMENT: LIMITIED MOBILITY, FRAGILE COMPLEX PT WITH MULTIPLE COMORBITIES. UNSTABLE CAREGIVERS.PLAN: RECERT FOR SN 3W2, 2W6 FOR WOUND CARE, CATH CHANGES, TEACHING OF CG FOR EARLY SIGNS/SYMPTOMS HEART FAILURE USING ZONE TOOLS. PT 3W2 FOR STRENGTHENING WITH TRANSFERS AND CG TRAINIGN OF APPROPRAITE TRANFER TECHNIQUE TO REDUCE RISK OF SKIN TEARS. ................
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