GET IT RIGHT! NOW NA!

JCIA 2012 Newsletter

August
July17,
6, 2012

ASSESSMENT OF PATIENTS (AOP)

Effective patient-assessment process results in
decisions about the patients immediate and
continuing treatment needs for emergency, elective,
or planned care, even when the patients condition
changes. Patient assessment is an ongoing, dynamic
process that takes place in many inpatient and
outpatient settings and departments and clinics.
Patient assessment consists of three primary
processes:
Collecting information and data on the patients
physical, psychological, social status, and health
history
Analyzing the data and information, including the
results of laboratory and imaging diagnostic tests, to
identify the patients health care needs
Developing a plan of care to meet the patients
identified needs
AOP.1 All patients cared for by the organization
have their health care needs identified through an
established assessment process.
AOP.1.1 defines the scope and content of
assessments, based on applicable laws and
regulations and professional standards.
AOP.1.2 states that all patients are assessed for
physical, psychological, social, and economic factors,
including a physical examination and health history.
AOP.1.3 requires that the patients medical and
nursing needs are identified from the initial
assessments and recorded in the clinical record.

AOP.1.4 defines that all initial assessments are

completed within the first 24 hours after the
patients admission.
AOP.1.5 requires that all assessment findings are
documented in the patients record.
AOP.1.6 Patients are screened for nutritional
status and functional needs and are referred for
further assessment and treatment when necessary.
AOP.1.7 All inpatients and outpatients are
screened for pain and assessed when pain is
present.
AOP.1.8 is about initial assessments for special
populations cared for by the organization.
AOP.1.9 Dying patients and their families are
assessed and reassessed according to their
individualized needs.
AOP.1.10 The initial assessment includes
determining the need for additional specialized
assessments.
AOP.1.11 The initial assessment includes
determining the need for discharge planning.
AOP.2 All patients are reassessed at intervals based
on their condition and treatment to determine
their response to treatment and to plan for
continued treatment or discharge.
AOP.3 Qualified individuals conduct the
assessments and reassessments.

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AOP.4 Physicians, nurses, and other individuals and

services responsible for patient care collaborate to
analyze and to integrate patient assessments.
AOP.5 Laboratory services are available to meet
patient needs, and all such services meet
applicable local and national standards, laws, and
regulations. AOP.5.1 to 5.11 detail laboratory
service requirements including a safety program,
timely release of results, quality control, and

established normal values with which to compare

the results.
AOP.6 Radiology and diagnostic imaging services
are available to meet patient needs, and all such
services meet applicable local and national
standards, laws, and regulations. AOP.6.1 to 6.10
detail radiologic and imaging services requirements
including availability and accessibility at all times, a
safety program, timely release of results, and quality
control.

Mock Tracer Sample Questions for AOP

These questions may also be applicable for other staff and in other units in the hospital. Use these questions as your own
review tool.
What could be asked
Medical/Surgical Nurse
[1] What kinds of assessments do you conduct when a patient arrives on the medical/surgical unit? Who conducts these
assessments?
[2] How do you document medication use?
[3] How do you assess for pain? What kind of monitoring and re-assessment do you perform? What tool do you use?
How is re-assessment documented?
[4] Have you assessed the patient for falls risk? Do you conduct on-going falls risk assessments? What interventions have
you put in place to reduce the patients risk of falling? Have you provided education to the patient and family regarding
falls prevention?
[5] With regards to cultural competency, what kind of special assistance do you provide to patients and families? How do
you accommodate special needs?
[6] Did you assess the patient for skin and pressure ulcer risk?
Psychiatry staff
[1] When do you conduct suicide risk assessments? How are such assessments documented? What do you do when
potential risk factors are identified?
[2] Could you describe a potential risk factor?
[3] If a patient attempted suicide in a medical/surgical unit, what would transpire? How are staff members able to
prevent a potential suicide? What would be done to assure that the patient remains safe for the remainder of his
hospitalization?
Medical/Surgical head nurse or supervisor
[1] What kind of process do you have to separate potentially infectious patients? How are they segregated?
Surgeon
[1] What kind of post-operative care did you order for this patient? How are you kept apprised of the patients condition?
*2+ How often do you visit the patient and assess the patients condition?
Pre-operative Nurse
[1] What are the pre-operative activities are taking place for a patient like ___?
[2] What kind of pre-operative assessment do you conduct?
ER staff
[1] What kind of assessments do you perform?
[2] How do you assess, respond to, and monitor for pain for emergency department patients?
[3] What is your triage process? How do you care for a patient who might have emergent needs?
JCI Newsletter TEAM
Lead Editor: Khenna Jimenez
Contributors:
JM Acuin
Jun Ylarde
Beth Vargas James Cayabyab
Jen De Dios

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Ways to ace AOP Among Inpatients

An admitting SOAP is written by the Attending Physician together with every inpatient admitting
order.
Residents incorporate their own Patient Database Form (PDF) in the patients chart within 12
hours of admission.
Nurses complete their Patient Assessment Form (PAF) within 8 hours.
Emergency room admissions are assessed immediately (emergent cases), within , respectively.
Patients undergoing anesthesia or sedation undergo 2 assessments.
o pre-anesthesia assessment by the attending anesthesiologist or the APEC consultant on
duty within 12 hours before anesthesia
o pre-induction assessment by the attending anesthesiologist immediately before
induction
o the anesthesiologist or a credentialed non-anesthesia provider conducts the presedation and pre-induction assessments
Psychosocial assessment of inpatients
NIC evaluates patients emotional status and mood using PAF
NIC asks patient and family about the availability and effectiveness of the patients social
support from family and friends in the community. These are noted on the PAF.
NIC also notes on the PAF
o risk factors such as signs and symptoms of physical / mental abuse, substance use,
dementia and other socially stigmatized disorders
o the patients spiritual practices and needs.
NIC and AP use tact and discretion in inquiring about these matters.
NIC and AP keep information confidential.
If needed, NIC and AP work together to refer patient to Psychiatry and other specialties.
Screening and assessment for vulnerabilities
NIC uses vulnerability screening form to note for physical and biological vulnerabilities.
NIC alerts AP of the need for further assessment and possible referral to other units such as
Psychiatry, Social Service, Rehab, etc.
Screening for high risk patient discharge planning
AP and nurse fill out High Risk Patient Discharge Planning Form for
Child or elderly with physical and/or social impairment
Frail elderly (older than 85)
Terminally ill patients on full or partial life support, including those on dialysis
Cancer patients
High risk pregnancy
Patients who sustained severe or profound trauma and/or abuse
Patients with severe end organ failure, including comatose or stroke patients
Psychiatric patient (suffering from mental illness, victims of physical / psychological / substance
abuse)
Patients with highly communicable diseases (such as HIV/AIDS, MDR TB)
Patients with chronic and severe pain and/or chronic and severe functional or neurological
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Economic assessment
Admitting Section staff inquires about
and notes patients profession or
occupation, employment details, mode
of payment and person responsible for
patients hospitalization on Patient Data
Sheet.
Resident documents the patients
educational background, religion
(particularly if non-Christian),
occupation and interests in the
personal and social history on the PDF.
Ethnicity (particularly cultural minority
status) is also noted.
The patients psychological, social, cultural,
family, and economic situation are considered
in
Obtaining the informed consent
Selecting diagnostic and treatment
options
Developing the overall treatment plan
Communicating and educating the
patient and family
Planning for discharge
Nutritional screening and assessment
Important information: BMI, appetite,
diet formula if appropriate on the PAF
If needed, refer to Nutrition
Management and/or Physical Med and
Rehabilitation
Functional screening and assessment
NIC notes mobility and independence in
performing activities of daily living on
the PAF.
If needed, NIC and AP work together to
refer patient to Rehab and other
specialties.
The information in the PAF is used not individually
but instead should be taken together to give the
healthcare team a holistic picture of the
patients status.
Pain
o Use standard pain scale to accurately
assess patients pain
o Assess for any current or chronic pain

Take note of patients pain medication

or treatment if any
o May refer to Pain Management
Risk for falls
o Accurately use the falls risk assessment
tool the appropriate fall prevention
protocol
o Relate patients falls risk with other
assessment information like functional
screen
Pressure ulcer
o Absence or risk for development of
pressure ulcer signal appropriate
preventive interventions
o Relate pressure ulcer assessment with
other information like functional
screen and mobility
Pain assessment in inpatients
Nurse in charge first screens for pain
using the visual analogue scale.
If the pain is in more than 2 locations
the nurse in charge asks the patient to
describe the pain in terms of duration,
factors that relieve or increase it, and
the current treatments.
NIC refers patient to AP who conducts
his own assessment and decides on the
intervention.
AP and NIC monitor the patients
response to pain management through
repeated assessments and physical
examinations.
Re-assessments
Conducted by physicians at least once
every 24 hours
More frequent in patients with urgent
and emergent needs, undergoing
surgical or high risk procedures,
requiring intensive care and who
experience unexpected outcomes
More intensive for high risk and
vulnerable patients
Conducted by nurses at start and finish
of every nursing shift
Should trigger appropriate, needsspecific, coordinated, and timely
responses from the healthcare team
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Using re-assessment information

Compare pain assessment with
previous pain status
Risk for falls should minimize previously
identified risks

Compare working diagnosis relative to

previous or initial clinical impression
Compare findings from physical
examinations
Use patients response to medication to
guide subsequent medications

Ways to Ace AOP Among Outpatients

If patient is for a routine diagnostic test, the staff uses the Outpatient Information and Assessment Form
(OIAF) to assess
Reason for having the diagnostic test (to direct patient to appropriate unit)
Needs for assistance in moving about or communicating with others (to provide patient with
wheelchair or communication aid, if needed)
Prolonged bleeding, easy bruising and known allergies (so that staff can anticipate potential
adverse effects of phlebotomy, use of dye, etc)
Pain score (to alert staff to possible diseases that can produce pain)
Preparations for tests, if needed (to determine if patient has taken proper preparation)
Last Menstrual Period (to limit or cancel radiologic studies, depending on the age of gestation)
If patient is for a special diagnostic test or procedure
Use OIAF
Use pre- and post-procedure assessment in the unit where the special test will be performed
If patient is for treatment or surgery
Use pre- and post-procedure assessment in the unit where the treatment or procedure will be
performed

Patient Assessment Form: strengths and weaknesses

Systems and Quality Department (SQD) monitors completion of our Patient Assessment Form (PAF).
Our overall compliance to PAF completion is 98% in 2012 (from 90% in 2010 and 95% in 2011)
The significant areas with marked improvement in compliance are:
o System Assessment (from 91% in 2011 to 99% in 2012)
o Nutrition Assessment Screening (from 92% to 98%)
o Psychosocial Assessment (from 92% to 98%)
o Current Medication and Treatments (from 94% to 99%)
Kudos to our consistent TOP PERFORMERS: 7/F Wellness, 5B and 12A
Assessment of spiritual needs has to be
improved; completion rate was 74% in 2011 and
94% in 2012)

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MUZIKLABAN ROCKS THE DOCK

July 27, 2012. TMC Loading Dock
Loading dock
transformed

Fynanzers overall
Muziklaban champs
Senior management getting
ready to rock n roll
TMC residents all out to cheer
for their favorite
band

Banda Lito.

and Banda Dawn

Hosts Pepe Cuarte and Hanna Nagrampa

Celebrity judges
Save Me Hollywoods mini concert
ICUs Sinus Rhythm 2nd placer
ASMPH Bands vocalist
Moonstar 88
Nurses jams it up!
The Chip Girls

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