PROTOCOL FOR ASSESSMENT AND PROGRESS (SNAP) NOTE, INCLUDING THE MAR

General Instructions: 1. When you send your note to the office, which automatically applies your electronic signature and professional designation, you are verifying that all documentation is accurate and has been checked by you for completeness. As a nursing professional, it is your responsibility to submit “error-free” documentation. 2. When you “check” a box, the expectation is that you have indeed completed that task or assessment. THE IMPORTANCE OF THIS CANNOT BE OVERSTATED. TCPS has a zero- tolerance policy for nurses checking off items that have not truly been done. 3. This form is intended to serve as a means of conveying your use of the nursing process throughout your shift; that is, assessment, plan, intervention, and evaluation. It also serves as your timecard and is the document from which we bill our payor sources. It includes your systematic assessment of the , especially noting areas of concern in the initial assessment by body system portion of the note. Your on-going assessment, plan, interventions, and the outcomes of those interventions should be reflected in your narrative charting. The Bullet Point Shift Report (BPSR) section allows you to briefly highlight concerns and outcomes for follow-up by the on-coming shift, as well as provide the Case Manager with pertinent information re: the patient and progress toward goals. 4. The first two pages of this form relate to what you have done as a skilled nurse on your shift. It is made complete by the entries on the MAR PLUS on subsequent pages (3 – 7).

Specific Instructions: (from top of page 1 to bottom of page 2) 1. Patient name: Select your patient from the drop-down menu of who have been assigned to you. 2. Open a new note from your home page, select a Billing Code (single, double, triple care). If you work in a home with multiple clients and you will be changing from one rate to another (single – double – triple) choose the Billing Code that applies to the majority of your shift. E.g., working a 9 hour shift – 5 hours as single care (with client A) & 4 hours double care (with client A and B), pick single care for “A” and double care for “B” from the drop down menu, and input the Time In at the start of your shift. Complete the Time Out at the end of your shift, after you have checked your notes for accuracy and completeness, then send the form to the office. Times in and out can be rounded to the nearest 15-minute increment. MAKE SURE YOU HAVE THE RIGHT DATE ON THE FORM!! Contact your supervisor if you have questions about how to log your time. 3. Safety check complete: (required) DO THIS AT THE BEGINNING OF YOUR SHIFT. By checking this box, you are indicating that you have checked the bedside equipment (oxygen, spare trach – current size and one size smaller for emergency, sx equipment and supplies, humidifier on and

1 | Page Rev. 02/2020 water level checked, battery level on vent – detachable and internal battery for the portable vent - vent plugged in); emergency equipment, and infection control supplies. Check the Specific Patient Information and Guidance (SPIG) form for exact information on your patient. DO ANOTHER SAFETY CHECK AT THE END OF YOUR SHIFT. You will document that you have done this by checking the box in the narrative portion and adding the time in the text box to the right. 4. Goals reviewed: (required) DO THIS AT THE BEGINNING OF YOUR SHIFT. By checking this box, you are indicating that you have reviewed the SMART goals that are under the GOALS/Specific Patient Information tab in the patient chart. These goals will help guide your narrative and BPSR charting because it is important to show progress toward goals. 5. MAR reviewed: (required) DO THIS AT THE BEGINNING OF YOUR SHIFT. By checking this box, you are indicating that you have reviewed the MAR, so you know which medications, treatments, feedings, and cleanings are due or available for this patient on your shift. To view the previous shift MAR, you can either open the SNAP note prior to yours (PRN’s done by the previous shift should highlighted for you in the BPSR) OR you can view PRN Interventions and Meds in the BPSR summary that you access from your home page. 6. Previous shift bullet points reviewed: (required) DO THIS AT THE BEGINNING OF YOUR SHIFT. By checking this box, you are indicating that you have read the Bullet Point Shift Report on page 2 of the previous nursing shift. You can find this by opening up the note from the prior shift to read their report. You will be able to view the previous MAR and BPSR in the same note, since the MAR is part of the SNAP note. OR To see a summary of BPSR’s, go to your home page and click on Bullet Point Shift Report Summary. There you can filter by date to see as many BPSR’s as you like, whatever you think will be helpful to you as a nurse as you plan your cares. 7. Trach size verified: (if applicable to your patient) DO THIS DURING YOUR ASSESSMENT AT THE START OF YOUR SHIFT. By checking this box, you are indicating that the actual trach that is in place matches the size/type of what is on the MAR in the Cleaning or Treatments Section for this patient. 8. Vent humidity system verified. (if applicable to your patient) DO THIS DURING YOUR ASSESSMENT AT THE START OF YOUR SHIFT. By checking this box, you are indicating that you have examined the amount of fluid in the bag and in the water reservoir to ensure that it is adequate, and that there are no kinks of flaws in the system. 9. Vent settings verified. (if applicable to your patient) DO THIS DURING YOUR ASSESSMENT AT THE START OF YOUR SHIFT. By checking this box, you are indicating that you have checked the actual settings on the vent to ensure they match what is on the MAR in the Treatments Section. 10. G/JB size verified. (if applicable to your patient) DO THIS DURING YOUR ASSESSMENT AT THE START OF YOUR SHIFT. By checking this box, you are indicating that the actual button that is in place matches the size/type of what is on the Master MAR in the Cleaning or Treatments Section for this client. 11. : The first set of vitals should be taken DURING YOUR ASSESSMENT AT THE START OF YOUR SHIFT. Subsequent readings (at least every 5 – 6 hours) should be input on subsequent lines. Refer to SPIG form for frequency of VS for your client. It is best practice to obtain at least a

2 | Page Rev. 02/2020 partial set of vitals in the last hour of your shift. If your shift is longer than 5 hours, the expectation is that there will be at least two sets of vitals on page 1. THIS IS THE ONLY AREA OF PAGE ONE THAT YOU WILL GO BACK AND ADD TO DURING THE COURSE OF YOUR SHIFT. ALL OTHER NEW ASSESSMENT FINDINGS, after the initial assessment, WILL BE INCLUDED IN YOUR NARRATIVE NOTE. 12. The Total Body Assessment by system: The next seven* areas will be completed by you DURING YOUR ASSESSMENT AT THE START OF YOUR SHIFT. Our practice is to conduct a complete skilled and note areas of concern; that is, abnormal findings based on a skilled pediatric nursing assessment. Common areas of concerns are provided, and each body system includes an “other” line for additional findings of concern/abnormalities. If you check any areas of concern or any history of concern, your nursing process to address these areas should be evidenced in your narrative note. You are expected to conduct a skilled head-to-toe nursing assessment. You do NOT have to chart assessment findings that are within normal limits for a pediatric skilled nursing assessment (e.g. clear lungs, regular heart rate, etc.) IF there are no concerns after you have completed your assessment, check the box “no areas of concern identified after assessment.” This is the only time you would check this box. It is there to demonstrate that you have in fact conducted an assessment in each particular area and that you have not identified any concerns – instead of the whole area being left blank. IF there is a history of concerns, but the patient is not exhibiting them at the time of your initial assessment, pls check the “History of concerns” and complete the text box to the right. This box/text area is there so that you can make note of concerns that are applicable to your particular patient – they are things you will want to watch for, and document to based on the SPIG form and the patient’s SMART goals. For instance, if the patient has occasional bradycardia or tachycardia, but it is not occurring on your shift, you should add it to the History of Concerns section in Cardiovascular. The “Other” line is for abnormal findings/concerns that you have identified that are not in the common areas of concern that we already have on the form. 13. *The seven areas are: a. NEUROLOGICAL – Always indicate either alert, sleepy, asleep, lethargic, or restless for LOC (level of consciousness). Neurological assessment includes orientation, sleep, seizures, need for restraints, pain, and behavior. Other neurological assessment items such as senses, communication ability, and developmental issues will be addressed on the comprehensive assessment done by the Case Manager. You are not required to add those here. b. RESPIRATORY – Always indicate whether or not a client is on oxygen or has oxygen available per the MAR. Respiratory assessment includes lung sounds, breathing effort, cough, secretions, and results of suctioning if done with your initial assessment. If prior shift reports that a client has had an increase in the need for suctioning, indicate that here. All other interventions that deal with secretions will be documented in your narrative note, along with the outcomes of the interventions. REMEMBER – YOU SHOULD HAVE ALREADY VERIFIED THE SIZE OF THE TRACH AS INDICATED ABOVE.

3 | Page Rev. 02/2020 c. CARDIOVASCULAR – Assessment includes listening, observing, and palpating. Indicate areas of concern as appropriate. d. GASTROINTESTINAL – Always indicate the date of the last BM. Gastrointestinal assessment includes abdominal assessment, bowel elimination status, tolerance to feedings, and hydration status. This is the area of assessment for intake of any type and output of stool, emesis, or residuals. Nutritional status will be documented on the comprehensive assessment done by the Case Manager. You are not required to add this here. REMEMBER – YOU SHOULD HAVE ALREADY VERIFIED THE SIZE OF THE G/JB AS INDICATED ABOVE. e. GENITO-URINARY – This is the area of assessment for genito-urinary concerns. Indicate areas of concern as appropriate. f. MUSCULOSKELETAL – Always indicate whether or not repositioning is required, versus the patient being able to reposition by themselves/independently. Musculoskeletal assessment includes changes in ability to move or unusual extra, involuntary movements. Musculoskeletal patterns and need for therapies will be included in the comprehensive assessment by the Case Manager, with input from PT/OT. You are not required to add those here. g. INTEGUMENTARY – Assessment includes all skin and sites. If concerns are identified, describe your assessment in the space provided. 14. BULLET POINT SHIFT REPORT – THIS IS THE AREA THAT WILL BE REVIEWED BY THE NEXT NURSING SHIFT AS WELL AS THE CASE MANAGER. IT SHOULD BE COMPLETE, CONCISE AND TO THE POINT. - The BPSR is the best place to see: your shift summary or report, PRN meds There are three areas under new/ongoing concerns: 1) Infection concerns: if applicable write in the textbox and indicate “new” or “ongoing” from the drop-down box. OR check “N/A” from the drop-down box if there are no concerns identified. Relay only current concerns. For example, a trach/vented child will always be at increased risk of upper Respiratory Infections, that does not need to be noted as ongoing concern. An example of an ‘ongoing infection’ concern – “day 6 of 14 of antibiotics for a UTI” 2) Safety concerns: if applicable write in the textbox and indicate “new” or “ongoing” from the drop-down box. OR check “N/A” from the drop-down box if there are no concerns identified. 3) “OTHER” is where you will list new/ongoing concerns in bulleted or numbered fashion. (one or two words is fine. In fact, do not try to write complete sentences here – we are after bullet points, so we don’t lose concerns from shift to shift. This does not need to be the same every shift. This will change based on the client’s condition. Refer to SPIG form to find what info case manager is looking for. A bullet list of concerns (such as: 1) L ear drainage 2) pain/fever 3) no BM x 3 days is sufficient). a. PRN Interventions and PRN Meds should be checked and completed as needed. IF YOU PROVIDED ANY PERTINENT PRN INTERVENTION OR ANY PRN MED DURING YOUR SHIFT, YOU MUST INDICATE IT HERE. This is for the subsequent shifts to see as well as the Case Manager. A brief word or two for your PRN interventions, meds, and outcomes will suffice. (such as: 1) ear drops @1400), 2) acetaminophen @1400), 3) Bisacodyl suppository @1000) for PRN Meds) and 1) decreased drainage/cont to monitor, 2) afebrile, 3) large BM for Outcomes). For ease of following concerns, PRNs, and outcomes, please arrange or number them so that we can

4 | Page Rev. 02/2020 see the relationship between them clearly – as in the examples above. PLEASE INDICATE THE TIME YOU GAVE THE PRN MEDS as well as the dose if there is a range available. b. Outcomes: Outcomes for all prn interventions and meds must be indicated here, PLUS outcomes to SMART goals. You do NOT have to write a positive or negative outcome to ALL goals, but please note some (for example, skin remains intact; lungs clear, O2 Sats > 93%). We understand that you will document your on-going assessment, intervention, and outcomes in your narrative note, so we do not want you to duplicate your charting here. IF YOU INCLUDE A “SHIFT SUMMARY”, it should be included in the outcomes section of the BPSR. It is not needed in your narrative. 15. Report given to: you do not need a name here, just on-coming nurse, family, MOC, etc will suffice. Make sure if you are writing “report given to on-coming nurse” that there really is a nurse coming on duty. 16. Notified of changes in condition: complete the text box and indicate who you reported to as applicable. LPNs are required to contact the main number to speak with a nurse if they identify any new concerns, so the patient can be assessed by a RN who will provide direction to the LPN. This is in accordance with the Scope of Practice for LPNs. When to notify case manager: new medications or treatments, change in client’s health status, injury to self or patient.

PROGRESS NOTES: This is where you document your skilled nursing process (at least every two hours) We are interested in concise, professional, skilled nursing information here. We are also interested in client’s progress toward goals, which is why you will have reviewed the client’s goals at the start of your shift. If the client is relatively stable, and there are no concerns or PRNs, this is most likely BECAUSE you are there monitoring and managing. Instead of writing “client at baseline, no changes,” chart to goals, such as: “1200 – no airway concerns, lungs clear to bilaterally, no feeding intolerance noted as evidenced by (aeb or AEB) no residuals or bloating.” Or “2300 – client sleeping restfully, respirations even and non- labored, oxygen 2 Lpm via nasal canula.” If you consider what the client’s goals are, and all the critical thinking you do while you are with the client, there are many skilled nursing items to note. Your narrative note does not have to be long to demonstrate that your skills were necessary, just filled with skilled nursing data that is based on each client’s goals and plan of care.

Vent Readings Be sure to include variable vent readings that occurred during your shift. This means, for a client on a ventilator, in the narrative, at least every 4 hours you will document the current ventilator numbers. If your client is unstable, this will be required at least every 2 hours.

Document the current (actual): 1) , 2) tidal volume, 3) minute ventilation (RR*Vt), 3) PIP/IPAP, 4) PEEP/EPAP, 5) I:E ratio, 6) SpO2 on current FiO2, 7) humidifier temp. 8) If on the Trilogy vent: the leak.

Note: this is different than verifying the vent settings per orders that you mark on the MAR. These are the actual numbers you read on the ventilator at that time – variables.

5 | Page Rev. 02/2020 Skin Integrity It is expected that you will note condition of skin in diaper area with every diaper change. Note condition of skin at all sites (GB/trach/cecostomy/NG) every time you check the site. Note how a child is “safely transferred”; was it single person transfer, hand hold assist, mechanical lift? Routine Medications While you should not list every routine medication you give, it is great to note “scheduled meds and flush given per MAR, client tolerated aeb. . .” (no gastric distress, no discomfort, remained asleep…)

Just above the narrative notes section, there are check boxes for report received from, verification that initial assessment was completed, TIME and whether or not changes were noted for second total body assessment (if shift is longer than 5 hours), verification that you have accurately completed your MAR for your shift, and when your end of shift safety check occurred. These checkboxes and text areas are here so you do not have to re-write them in your narrative notes.

MAR Specific Instructions: (from top of page 3 to bottom of page 7) 1. The MAR Please follow the instructions at the top of page 3 for all pages. a. Checking a box indicates: given, complete, or verified b. Indicate time for every PRN c. Start at the left in the appropriate time slot and make subsequent entries to the right. Night shift nurses may need to ‘circle back’ to the left side. d. Indicate DBF if an item was given or completed by a family member during your shift. and Weight will be auto filled for you. 2. Routine and PRN Meds are on the first 2 and ½ pages (that is, pages 3, 4, and 5 of the SNAP note); then Treatments on the last half of page 5; then Feedings on page 6; and Cleanings on the bottom half of page 6 and onto page 7. Some patients who have a complicated Plan of Care, will have a relatively “full” MAR. Other patients will have some blank spaces on some of the pages. 3. Start date, Med and dose, or treatment, or feed, or clean, and whether or not it is routine or PRN will be auto-filled in for your patient. Times for routines will be auto-filled as well moving from left to right in the 12 time slots for each Med/treatment/feed/clean. 4. Since you will enter the time for PRNs, start in the first box and make subsequent entries to the right. 5. There are 12 time slots in case you need to initial/record something that must be done hourly (e.g., suction). It is appropriate to write how many times you suction in an hour time slot (for instance, at 10, 11 and 12, you suctioned 10 times/hour, indicate the time “1000” and “x10” in the text box, move to the right, indicate “1100” and “x10” in the text box, and so on. Also indicate where you suctioned by checking O, N and/or T. 6. BM log requires a description of the BM as well as the time.

6 | Page Rev. 02/2020 Completion Instructions 1. Remember to document the time out (pg. 1) for your shift. If you have reported off to another nurse, the time out on your SNAP Note should reflect the time that you stopped caring for the child If necessary, submit additional time spent on documentation after the patient handoff as admin time via the Payroll Extra Items form. 2. Your note will be “signed” by you electronically when you send it to the office. Before you send it in, please review ALL SEVEN PAGES for accuracy and completeness. Do NOT send your charting to office more than 5 minutes BEFORE the end of your shift! 3. Send your note to the office. Notes need to be sent to the office at the end of the visit (before you leave the patient’s home). You will not be paid for shifts worked if your visit note is sent in late without prior approval. Approvals are only granted for emergent events and for unforeseen circumstances such as lack of internet access. Call the office at 970-686-5437 to request an approval. If you do not have a qualifying event, you are expected to submit documentation prior to leaving the home. The MAR and Bullet Point Shift Report must be completed before leaving the home even if you have gotten an approval for an extension.

Associated Documents Skilled Nursing Assessment and Progress Note PDN Documentation Checklist PDN Documentation Manual

7 | Page Rev. 02/2020