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

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) 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!! If you have questions about how to log your time, please contact your supervisor. 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 water level checked, battery level on vent – detachable and internal battery for the portable vent -

Rev. 3/2019 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 PLUS 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 PLUS 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 PLUS in the Cleaning or Treatments Section for this patient. You do not need to state that patient has a trach in the Respiratory Section. 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 PLUS 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 MAR PLUS in the Cleaning or Treatments Section for this client. You do not need to state that patient has a G/JB in the Respiratory Section. 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 hrs) should be input on subsequent lines. If your shift is longer than 5 hours, the expectation is that there will be at least two sets of

Rev. 3/2019 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 a sleep disorder, but it is not occurring on your shift, you should add it to the History of Concerns section. 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, 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 AND EXISTENCE OF THE TRACH AS INDICATED ABOVE. c. CARDIOVASCULAR – Assessment includes listening, observing, and palpating. Indicate areas of concern as appropriate.

Rev. 3/2019 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 AND THE EXISTENCE 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. 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. A bullet list of concerns (such as: 1) L ear drainage 2) pain/fever 3) no BM x 3 days) is sufficient). 15. 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) bisocodyl suppos @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 see the relationship between them clearly – as in the examples above. PLEASE INDICATE THE TIME YOU GAVE THE PRN MEDS OR AT LEAST THE TIME YOU GAVE THE LAST DOSE, as well as the dose if there is a range available. 16. 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

Rev. 3/2019 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. 17. Report given to: you do not need a name here, just on-coming nurse, family, MOC, etc will suffice. 18. 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. 19. 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 bil, no feeding intolerance noted as evidenced by (aeb or AEB) no residuals or bloating.” Or “2300 – client sleeping restfully, resp. even and non- labored, oxygen delivery system operational @ 2/l min via nc.” 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. Be sure to include variable vent readings that occurred during your shift. 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, completion of therapy exercises, whether a communication device is in place, 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 PLUS Specific Instructions: (from top of page 3 to bottom of page 7)

1. The MAR PLUS – 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 d. Indicate DBF if an item was given or completed by a family member. 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

Rev. 3/2019 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 PLUS. 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 son 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. 7. 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.

Rev. 3/2019