FLORIDA STATE STATE OF FLORIDA OPERATING PROCEDURE DEPARTMENT OF NO. 152-5.5 CHILDREN AND FAMILIES CHATTAHOOCHEE, February 2, 2017

Nursing Services

NURSING DOCUMENTATION

1. Purpose: To comply with Florida State Hospital, State and Federal Standards and guidelines regarding documentation.

2. Scope: This operating procedure applies to all nurses and all Units at Florida State Hospital.

3. Policy: All shall be written in accordance with the references listed below.

4. References:

a. Florida Statutes 395, 464 (Nurse Practice Act) and 64B9 (Florida Board of Nursing Rules)

b. Florida Administrative Code, Chapter 59A-3, Hospital Licensure, Agency for Administration

c. Institutional Quality Management and Review, Manual 180-1

d. Children and Families Operating Procedure 155-1, Use of Psychotherapeutic in State Mental Health Treatment Facilities

e. Children and Families Operating Procedure 155-5, Supervision of Unlicensed Assistive Personnel Performing Nursing Delegated Tasks and Activities in Mental Health Treatment Facilities

f. Florida State Hospital Operating Procedure 150-35, Unit Dose System

g. Florida State Hospital Operating Procedure 151-3, Recovery Planning

h. Specialty Care Operating Procedure 151-14, Documentation of Individualized Recovery Plans

i. Florida State Hospital Operating Procedure 151-17, Documentation on Individualized Recovery Plan Needs List

j. Florida State Hospital Operating Procedure 152-5.8, Observation and Documentation of Resident’s Weights and

k. Florida State Hospital Operating Procedure 155-11, Education/ Management Program

l. Florida State Hospital Operating Procedure 155-22, Seclusion and Restraints Use in Psychiatric Crisis Management

This Operating Procedure supersedes: Operating Procedure 152-5.5 dated February 17, 2016 OFFICE OF PRIMARY RESPONSIBILITY: Nursing DISTRIBUTION: See Training Requirements Matrix February2,2017 FSHOP152-5.5

5. Definition: : Nursing assessment is the first step in the nursing process. A careful and complete history must be obtained from the resident. The by the nurse will require visual and tactile inspection and , , and if needed/appropriate. Any deviations from the norm will be noted.

6. Procedure:

a. Data Sources:

(1) Documentation shall be based on direct observation, interviewing the resident, consultation with employees, reviewing documentation sources and feedback from family, friends or guardian. All entries shall be supplemented with a description of the actual behavior observed as well as changes in the resident’s psychiatric condition, statements of the resident, etc.

(2) Progress notes shall reflect involvement in monitoring of abnormal laboratory and x- ray reports.

(3) Progress notes shall reflect completion of admission and annual nursing assessment, with documentation of significant findings.

b. Documentation Regarding Physical Complaint/Illness or Psychiatric Complaint: Progress notes shall reflect documentation that the nurse was responsive to resident complaints and investigated, examined the resident following physical complaint/illness or psychiatric complaint, and followed up on those complaints requiring intervention. Complaints requiring a higher level of care will be referred to a physician/Advanced Registered Nurse Practitioner.

(1) When a resident has a physical complaint/illness or psychiatric complaint reported, a nurse shall evaluate the resident as soon as possible, and shall document said evaluation.

(2) The Situation/Background/Assessment/Recommendation (SBAR) communication tool (see Attachment) will be used as a guideline when contacting the physician. The name of the physician notified of the resident’s complaint/symptom, and the time notified will be documented in the .

(3) When cases involve the onset of acute symptoms, the resident’s vital signs are recorded at the onset (temperature, , respiration, ). Vital signs shall continue to be monitored at regular intervals while acute symptoms are present according to the nurse’s clinical judgment unless otherwise ordered by a physician. When there are negative changes in the resident’s vital signs, the nurse will immediately request physician assistance; take another appropriate action, or provide a rationale for no action beyond current status. All acute problems/needs require documentation until resolution.

(4) The primary nurse will as soon as possible upon any transfer of resident care from one area to another provide a verbal report for the nurse receiving the resident. This report should include current situation, any pertinent background, assessment findings that include current vital signs and other information pertinent to the situation/resident issue.

(5) The primary nurse should also ensure that pertinent information such as the resident chart, MAR’s, and current flow sheets follow the resident to the place of transfer. The chart with all pertinent documents should be delivered to the nurse of the receiving Unit/Dorm.

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c. Documentation Regarding Nursing Observation and Interventions:

(1) The nurse shall document significant observations including vital signs, nursing interventions, and resident’s response. All unusual/unexpected reactions or behavior shall be documented and immediately reported to a physician with documentation of physician’s name and time notified. If physician is not notified, a rationale shall be documented.

(2) The nurse shall document significant observations made by direct care staff, the resident’s family, friends, and/or guardian. (CFOP 155-5).

d. Documentation Regarding Medication:

(1) Guidelines for progress notes regarding medications as required by Florida State Hospital Operating Procedure 150-35, Unit Dose Systems shall be followed.

(a) omission of medications

(b) refusal of medications

(c) any deviation from scheduled administration times including reason and action taken

(d) parenterals: date, time, route, injection site, the response and cooperativeness of resident, and whether Z tract method is used

(e) any deviation from the routine administration

(2) Baseline vital signs when ordered by the physician, prior to the administration of medication.

(3) Any resident teaching regarding expected benefits and potential side effects of medication. (See requirements in Florida State Hospital Operating Procedure 155-11, Medication Education/ Management Program.)

(4) Any assessment/monitoring in regard to: resident’s response, side effects, adverse effects, response to new medications, dosage changes, or discontinued medications.

(a) Medication Effects:

1. The nurse shall document his/her observations of the effects of therapy on motivation, learning and specific symptoms related to thinking, mood, behavior and/or behavior problems in such a manner as to provide a basis for further medication evaluation.

2. The nurse shall also incorporate into his/her progress notes significant observations and documentation made by direct care staff in regard to effectiveness of medication, side effects or adverse reactions.

(5) PRN (pro re nata [as often as necessary]) Medications:

(a) The nurse administering PRN medications shall document in the the nursing observation including vital signs. Within one hour of the PRN administration, the nurse shall document in the progress note the resident’s response to the PRN medications.

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(6) STAT Medication as required by Institutional Quality Management and Review:

(a) A nurse shall document in the progress note that a STAT medication is given within the 30 minute time frame. If the STAT medication is not given within 30 minutes, the progress note shall reflect the rationale for the order not being completed within the appropriate time. Documentation shall also reflect the resident’s response to the medication. (CFOP 155-1).

e. Documentation Regarding Discharge: Prior to discharge, progress notes shall reflect documentation of the resident’s discharge readiness, in regard to nursing follow-up care. The nursing section of all hospital and statewide discharge forms (including Form 7001) shall be completed with relevant information within the required time.

f. Admission and Annual Nursing Assessment:

(1) The nursing assessment shall be completed by the residential unit Registered Nurse within 24 hours of admission and annually, prior to the anniversary date of the month of admission and documented on Form 31, Nursing Assessment.

(2) After completion, a copy of the section on Functional Disabilities and special needs shall be faxed to the Health Information Specialist for computer input and then the original filed in the ward chart.

g. Medication Education Assessment: To be completed by the residential unit Registered Nurse within 24 hours of admission, and at least annually based on the admission date and documented on Form 43.

h. Nursing Progress Notes: Nursing documentation shall be performed in a professional and systematic manner that supports the nursing actions taken during the course of resident care. Nursing progress notes are numbered according to the treatment issue/need to which it relates.

i. Admission/Weekly/Monthly Documentation:

(1) An shall be written at the time of admission.

(2) Following the admission progress note, goal-directed summary progress notes shall be written weekly for the first four weeks of hospitalization and monthly thereafter by the registered nurse. The first weekly progress note shall summarize any pertinent information from Form 32, Ward Staff Admission Note, and Form 26, Direct Care Assessment. Progress notes shall be written the first eight weeks in Distinct Care Ward, Specialty Care Unit. (CFOP 155-39; CFOP 150-34). A Licensed Practical Nurse may assist the Registered Nurse in gathering and recording information on the Nursing Monthly Progress Note (Form 78). The Licensed Practical Nurse will note that information was forwarded to the Registered Nurse for review. The Registered Nurse will review the Licensed Practical Nurse data and document said review along with resident progress on Progress Notes (Form 52).

(3) The weekly summary may be completed on Form 78, Monthly Progress Notes- Nursing. If the weekly summary is written in the progress notes, it shall have a heading and be underlined.

The monthly summary shall be completed on Form 78, Monthly Progress Note - Nursing, and Form 79, Monthly Progress Note - Nursing Addendum. Each monthly note is due no more than 30 days from previous note.

j. Medical Services and Specialty Care: These units shall follow their unit specific policy regarding frequency of documentation.

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k. Nursing Care Plan:

(1) The nursing care plan shall be written by a Registered Nurse and is a component of the Recovery Plan. (Medical Services is an exception to this since the nurses write the nursing care plan according to unit policy.)

(2) Nursing input into initial Recovery Plan: Following completion of the admission nursing assessment, relevant health and safety issues shall be placed in the Initial Recovery Plan according to Florida State Hospital Operating Procedure 151-3.

(3) Recovery Plan: Nurses with assigned caseloads are expected to provide input for nursing issues. Nurses shall complete the following:

(a) Comprehensive assessments/evaluations at times specified in Florida State Hospital Operating Procedure 151-7.

(b) Conduct a Pre-Recovery Plan Meeting with the resident at least five (5) days prior to the scheduled Recovery Team Meeting per Florida State Hospital Operating Procedure 151-3.

Resident involvement and agreement shall be sought during this meeting. Document the topics that were discussed and the resident’s perspective and feelings surrounding these issues in the progress notes. The progress note shall indicate specifically if the resident is in agreement with the planned course of treatment and, if not, the justification for including objectives in the plan based on health, safety, or security reasons. Following the meeting with the resident, the nurse will make amendments on the issues list at least five (5) days prior to the scheduled Recovery Team meeting.

(c) Nurses are responsible for the following:

1. provide services as identified in the Recovery Plan

2. document the results of and the resident’s response/reaction to the following in the progress note:

a. ongoing assessments or evaluations

b. recommendations to or explanations for changing services

c. significant changes in resident progress (positive and negative)

d. significant interventions or interactions with the resident

e. resident progress toward Recovery Plan objective(s), summarized monthly. Progress documentation shall be specifically related to the objective(s) stated on the Recovery Plan and the resident’s perspectives.

(d) Nurses shall follow the steps below when Recovery Plan revisions and additions occur in-between scheduled reviews:

1. meet with the resident to discuss proposed changes to plan; conduct meeting and document in the progress notes following guidelines indicated above.

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(e) In the event of psychiatric/medical emergencies, the nurse together with Recovery team shall:

1. meet with the resident to discuss proposed plan or changes to plan and document meeting.

(f) The Recovery Plan shall include but not limited to the following:

1. specific, measurable goals

2. goals stated in objective terms

3. goal completion time-frames

4. specific nursing interventions

5. personnel responsible for interventions

6. The Recovery Plan is regularly revised and updated to reflect the resident’s current status and goal attainment, as outlined in FSHOP151-3.

l. Documentation of Temporary Needs Plan: The Temporary Needs Plan shall be documented in the progress notes at the time the temporary need is placed on the needs list and shall:

(1) include a description of the need

(2) state interventions planned for the resident including any medication which has been ordered

(3) specify the names and title of staff assigned to carry out the assigned interventions

(4) be transferred to the Issues List and a Recovery Plan developed if longer than 30 days. Exceptions to this include any need that shall be resolved quickly (i.e., waiting for lab results, etc.). Then the need shall be closed and re-opened for a second 30 day period. Rationale shall be included in the progress notes.

m. Documentation Regarding Seclusion and Restraint: If residents are placed in seclusion/restraint, documentation shall be in accordance with Florida State Hospital Operating Procedure 155-22.

n. Forms: A Nurse is responsible for reviewing forms on a timely basis and incorporating pertinent information into progress notes and weekly and monthly summaries. Forms to review shall include the following:

(1) Form 18, Care Plan Implementation

(2) Form 35, Weight and Vital Signs (refer to Florida State Hospital Operating Procedure 152-5.8, Observation and Documentation of Residents’ Weights and Vital Signs)

(3) Form 348, Intake/Output Flow Sheet

(4) Form 13, Immunization/Treatment Record Communicable /Education Form

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(5) Form 605, Seclusion/Restraint Flow Sheet

(6) Form 69, Medical Restraint Flow Sheet

(7) Form 568, Pressure Ulcer Flow Sheet/Line Report

(8) Form 27, Cumulative Seizure Record

(9) Form 622, Treatment Record

(10) Form 15, Flow Sheet

(11) Form 75, Neurological Monitoring Form

(12) Form 350, Nourishment Record

(13) Form 579, Tube Feeding Record

(14) Form 553, Glucose Monitoring

(15) Form 181, Monitoring of Side Effects Scale (MOSES)

(16) Form CF-MH 2010/2010A, Dental Record

(17) Form 385, Eye Flow Sheet

(18) Form 43, Medication Education Assessment

(19) Form, Dietary Assessment

o. Resident Transfers: Documentation regarding transfer of residents shall be documented on Form 47, Service Transfer Form.

p. Documentation Regarding Laboratory Tests:

(1) Telephone calls from the Laboratory regarding abnormal lab results and medication blood levels shall be documented in the progress notes by the nurse, including documentation of the physician or Advanced Registered Nurse Practitioner who was notified.

(2) The nurse/designee shall document refusal in the progress notes

(a) The nurse shall document notification of refusals to Physician, Advanced Registered Nurse Practitioner or Physician Assistant in the progress notes.

7. Training Requirements: A check in the box below indicates which employees within the department are required to read this operating procedure and when they will receive training at Florida State Hospital. Employees within identified departments will also be required to review the policy each time it is updated.

New Discipline Worksite Annual Department Employee Specific Education Update Orientation Training All Employees

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New Discipline Worksite Annual Department Employee Specific Education Update Orientation Training Clerical Dental Dieticians, Laboratory, Special Therapy, X-Ray Techs Direct Care Emergency Operations Environmental Services (Aramark) Financial Services Food Services Health Information Services Human Resources Information Systems Legal Materials Management Nursing X Operations & Facilities (Aramark) Pharmacy Physician/ARNP (Prescriber) Professional Development Psychology Quality Improvement Recovery Planning Rehab Services Resident Advocacy/Risk Mgt. Social Services Supervisors/Managers Volunteer Services Other:

Attachment: MARGERITEJ.MORGAN SBARTelephoneReporttoPhysician Hospital Administrator

SUMMARY OF REVISED, ADDED OR DELETED MATERIAL

Added Paragraphs 6.b.4 and 6.b.5

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SBAR TELEPHONE REPORT TO A PHYSICIAN BEFORE CALLING THE PHYSICIAN 1. Assess the patient. Involve the patient in plan recommendations, if possible. 2. Review the chart for recent medication or order changes/changes in condition. 3. Know the primary/pertinent diagnoses. 4. Have the following available when speaking with the physician: Chart, , Meds, Labs/Results

Focus on the problem, be concise. Not everything in the outline needs to be reported-just what is needed for the situation. SITUATION State your name and from I am calling about: (Resident/Patient)

S The problem I am calling about is: (briefly state problem, when happened/started, and how severe. Code status would be helpful. (Unit 31 only) Notes:

BACKGROUND State the primary and pertinent diagnosis and . A Brief Synopsis of the treatment to date. State the pertinent assessment findings, vitals, etc. B Relate the complaint given by the patient and the pain level. Pay special attention to emotional/ mental status and skin temperature. Notes:

ASSESSMENT Give conclusions about the situation. Words like “might be” or “could be” are helpful. A diagnosis is not necessary. Relate how severe the problem might be: Change from prior assessment: Weight Blood Pressure Blood Sugar Mental Status Temperature Pain A Neurological changes / quality Wound Musculoskeletal Pulse rate/quality GI/GU (Nausea/Vomiting/ Diarrhea/Output) Notes:

RECOMMENDATION: Say what you think would be helpful or what needs to be done.  Change treatment to: ______ Adjust medications for: ______ Obtain consult for discipline (e.g., PT, OT, ST, etc.) ______R  Transfer the patient to hospital? Make sure to clarify under what circumstances and when the physician wants us to call again. Notes:

*Documentation: All telephone orders are to be read back to the physician or Advanced Registered Nurse Practitioner and documented as T.O./R.B./Dr______/Nurse name and title. Attachment 1 Page 1 of 1

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