Post on 16-Jan-2016
SOCIAL SERVICES
A QUALITY KEY
PRESENTED BY
Rhonda Anderson, RHIA
President, AHIS
Anderson Health Information Systems, Inc.940 W. 17th Street, Suite B
Santa Ana, CA 92706Tel. 714-558-3887Fax 714-558-13-2
Email office@ahis.net
TOP TEN KEYS TO QUALITY DOCUMENTATION
• KISS – Keep It Simple and Short
• Documentation System – Manual or automated, individualized to patient?
– Does your records include pertinent data and follow the format/content requirements?
• Don’t repeat information from others
• Keep the records/documentation sequential/organized
TOP TEN KEYS -2
• Timely, accurate, legible if manual; date, time entry and signed if automated
• Document completely and identify the patient clearly. Ensure documentations do not look like a “stamp” for all patients.
• Tell how you planned, what you did and the outcome
• Meet both State and Federal regulations
TOP TEN KEYS -3
• Assessments – In the old and the new regulations, assessments are still a part of the planning and delivery of services.
• Accuracy and completeness of assessments mean the resident and the related family/support system information. (Of course consent of the patient is important because without that you really have no resource beyond the patient.)
WHAT IS THE GOAL OF SOCIAL SERVICES?
• MAXIMIZE Support and Adjustment – “Patient and family”– What does that mean to you?
– Have you determined this with your interdisciplinary team?
– Do your policies and procedures reflect this approach?
– Have you included interest in transplant & f/up?
ASSESSMENTS
• Individualized
• Identify the patient’s past
• Disabilities aside from the ESRD issues
• Mental status previously and now
• Language barriers
• Past work life so the IDT can consider how that can be carried into today’s challenges
• Past compliance with food and nutrition
ASSESSMENTS -2
• Family relationship and status• Mental status in the past and currently
observed, i.e., medication side effects and social impact
• Support system, i.e., family, friends, employer• Resources needed, i.e., identification of
transportation, equipment, caregivers, medications
• Etc…etc.-- different for each resident
ASSESSMENTS -3
• Assessment is NOT only initial. It is an ongoing process as you see the patient, participate and assist the patient and family to participate in the treatment planning process.
• The initial assessment does assist with determining some of the immediate needs and barriers.
ASSESSMENT IS KEY!
Initial and ongoing assessment
WHAT ELSE CAN I DO TO IMPACT QUALITY OUTCOMES?
• To name a few:– Education
– Counseling
– Offering options
– Working with the I.D.T which includes the patient, family and support system
• Make certain notes reflect this ongoing assessment and involvement, working with the patient and others
WHAT ELSE CAN I DO -2
• Focus on the behavioral emotional issues and assist with calming that process
• Identify compliance with discussion with patient/family/others
• Anticipate problems and coordinate with I.D.T.
• Communicate and encourage participation in the plan of care
WHAT ELSE CAN I DO -3
• Evaluate and provide ongoing education about:– The dialysis process
– The family, social/work aspects and challenges
– Awareness of the emotional toll
– Psychosocial goals and life’s goals within the context of the dialysis needs
– Follow up on transplant interest
– Medication understanding of issues/w/nursing
WHAT ELSE CAN I DO -4
• Feedback from the patient on understanding of:– Dialysis
– Impact
– Medications side effects on emotions
– Sleep disturbance and approaches
– Etc.
WHAT ELSE CAN I DO -5
• Hospice services when that is applicable
• Emergency preparedness and travel support
• Teamwork!
WHAT IS THE OUTCOME?
• How do you measure what you have completed?
• A good job working with the patient, in that goals are met, if not met the I.D.T. is working with the patient.
WHAT IS THE OUTCOME? -2
• Document the activities and actions– on a regularly scheduled basis, quarterly is a
minimum; but not the expected– As activities and actions occur
COMPLIANCE WITH SURVEY STANDARDS
• What do surveyors expect?– Assessment – focus on the obvious – complete
assessment!!
– Care Planning – plan the findings from the I.D.T. assessment – involvement of the patient and dealing with the outcomes both positive and those where goals are not met
– Ongoing documentation of assessing the patient and follow up.
COMPLIANCE WITH SURVEY STANDARDS -2
• What do surveyors expect? (cont.)– Services supports – documented– Emotional and behavioral assessed and
addressed not only in some cases with the patient, their family and staff providing the dialysis services.
IT IS NOT NEW
• MAXIMIZE PATIENT COMPLIANCE TO TREATMENT!!!
• And you do it so well– Now document all those good services you
provide and show the outcome.
THANK YOU FOR ATTENDING