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Doesformatmatter?ExploringtheuseofatemplatefordocumentationintheEMR
EstherAmmon,LCSW,ACHP-SW4thSWHPNAnnualAssembly2016
* Explorethevalueofutilizingatemplateforpalliativeandhospicesocialworkdocumentationintheelectronicmedicalrecord(EMR)* Reviewanexampleofapalliativepsychosocialassessmentandf/unotetemplate* IdentifytoolsandstrategiesthatcanbeutilizedintheEMRtooptimizedocumentationofsocialworkcontributionsandsupportoutcomesmeasurement
Objectives
* Structuralfactors* Notelength* Informationdensity* Informationalquality* Documentquality
PrinciplesofDocumentation
Whatdothedatashow?
* Shenetal(2012)* Nerietal(2014)
* Marilletal(1999)
* Roseetal(2001)
* Template=documentquality
* Template=documentqualityforspecialists* Template=documentquality
* Template=documentquality
UseofTemplate
Advantages/Benefits* Increasedefficiency* Increasedorganization* Increasedcomprehensiveness* Enhanceinterdisciplinary
communication* Promoteuniformity
Disadvantages/Burdens* Focuson“checklist”* Focusonsequence* Decreasedevaluationtime* Increaseingrossbilling* Poordesign* Lesspatient/familycentered
* DocumentationGuidelines* NASW,NHPC,JointCommission,CMS
* Settingspecific(?Institutionguidelines)* UnitSW?* Specificjobdescription/requirements* SWAT,PIP
SWinPCandhospice
* EmphasisonInterdisciplinaryteam(IDT)engagementandcollaborationwithpatientandfamilies* Emphasisoncoordinatedassessmentandcontinuityofcare* Clarityandspecificityofinterdisciplinaryteamcomposition* Qualityassessmentprocess
Domain1:TheStructureandProcessesofCare
* Standard6.EmpowermentandAdvocacy.
* Standard7.Documentation.Socialworkersshalldocumentallpracticewithclientsineithertheclientrecordorinthemedicalchart.Thesemaybewrittenorelectronicrecords.
* Standard8.InterdisciplinaryTeamwork.* Standard9.CulturalCompetence.
AffirmationofNASWStandardsforPalliativeandEOLC
PALLIATIVECAREPSYCHOSOCIALASSESSMENTPreferredlanguage:LanguageUsed:SourcesofInformation:Barrierstoassessment:NoneNextofKin(NOK):***PrimaryCaregiver:OtherContacts:*** ChiefComplaint:Iamfeeling***HPI:Thisconsultationwasrequestedby***Supportsystem:()Strong()Fair()LimitedsupportsystemComments:Copingstatus-patient:Copingstatus-family:Physicalaspects:Learningneeds?()Language()Cultural()Developmental()Motivational()CognitiveComments:Religious/Spiritual/Existentialaspects:()Yes()NoComments:Assessment:PlanofCare:CoreMeasures: Yes No PalliativeCareEducation X PastoralCare X TherapeuticCounseling X AdvancedCarePlanning X X AssessStress X AssessCoping X AssessAnxiety X AssessAnticipatorygrief X FamilyMeeting X X Bio-ethicsconsult X X PCSInterdisciplinaryRounds X X
* Contactinformation* Reasonforconsult* Interventions* PsychosocialHistory* Advancedcareplanning* Assessment* Planofcare
Palliativepsychosocialassessmenttemplatecomponents
PALLIATIVECAREPSYCHOSOCIALASSESSMENTPreferredlanguage: LanguageUsed:SourcesofInformation:Barrierstoassessment:NextofKin(NOK):PrimaryCaregiver:OtherContacts:
TemplateExample
ChiefComplaint:Iamfeeling***HPI:Thisconsultationwasrequestedby***Supportsystem:()Strong()Fair()LimitedsupportsystemCopingstatus-patient:Copingstatus-family:Physicalaspects:Learningneeds?()Language()Cultural()Developmental()Motivational()CognitiveReligious/Spiritual/Existentialaspects:()Yes()NoAdvancedCarePlanning:Patientdoesnothaveanadvanceddirective.Goalsatthistime: ()Curative()Restorative()Longevity()TorelievedifficultsymptomsCodeStatus:FullPOLST(PractitionerOrdersforLifeSustainingTreatment):CandidateAssessment:PlanofCare:
CoreMeasures: Yes No
PalliativeCareEducation X
PastoralCare X
TherapeuticCounseling X
AdvancedCarePlanning X
AssessStress X
AssessAnxiety X
AssessCoping X
AssessAnticipatoryGrief X
ReikiSession X
FamilyMeeting X
Bio-ethicsconsult X
PCSRounds X
HPI:Thisconsultationwasrequestedby***.Ptisa***withPMHof***.Followingforpalliativepsychosocialassessmentandinterventioninsettingofseriousillnesstrajectory.Metwithptbedside.Introducedselfandsupportiverole.Ptabletoparticipatewithassessment.Amenablewithintervention.Pleasantandeasilyengaged.Ptreadilydiscussesillnessdescribing***Expressingfeelingsof****around***.Feelingsvalidated,normalized.Exploredwaysinwhichillnesshasimpactedlife,suchas***Confirms/deniesthatpain/symptomshaveimpactedcopingExploredhelpfulcopingstrategiessuchas***Reinforcedongoingavailabilityforpsychosocialsupportinsettingofseriousillnesstrajectory.
HPI&Intervention
Supportsystem:Copingstatus-patient:-Pleasantandeasilyengaged.-Describesnormativefeelingsofsadnessandlossarounddeclineinfunction.-Abletoselfsoothe.Abletolookforwardtothefuture.Copingstatus-family:ThemesofcumulativecaregiverfatiguePhysicalaspects:Reportshe/shewasindependentwithADL’spriortohospitalizationLearningneeds?()Language()Cultural()Developmental()Motivational()CognitiveReligious/Spiritual/Existentialaspects:()Yes()NoUtilizesfaithtocopewithstressofseriousillness.Importantspiritualresourcesinclude:***Whilehe/shehasnoformalreligiousaffiliation,he/shedoeshaveaspiritualphilosophythatguideshislife.Confirmsawarenessofpastoralcareasaresource.
PsychosocialHistory
Copingstatus-patient:Pleasantandeasilyengaged.Describesnormativefeelingsofsadnessandlossarounddeclineinfunction.Ptexpressesdepressivesymptomsincludinginsomnia,
anhedonia,hopelessness,poorinterestor concentration,lowenergy.Patientdeniesanysuicidal/homicidalideationswithintentorplan.
Smartphrases
AdvancedCarePlanning:Patientdoesnothaveanadvanceddirective.
PatienthasanAD.Reviewed,copylocatedinchart.CodeStatus:FullPOLST(PractitionerOrdersforLifeSustainingTreatment):CandidateWhenasked,"WhatshouldHackensackUMCknowaboutyouandyourlovedonesinordertotakebettercareofyou?"*****Assessment:Mr/Ms.***-Currentpainlevelacceptable.-Appearstobehavingunderstandabledifficultycopingaround***-Understandablethemesofloss,sadness,anticipatorygriefnoted.-Likeallpatient/famliesexperiencingseriousillness,Mr/Ms***.andfamilyconfrontseveralemotionalchallengeswhichmaybesupportedwithongoingmonitoring,explorationandsupport.
ACP,Assessment
PlanofCare:-Willcontinuetoexplorewaystoenhanceadaptivesuchascognitive-behavioral,strengths-basedandshorttermtreatmentinterventions-Willcontinuetomonitorpt/familycopingandremainavailableforpsychosocialinterventionaspt/familysystemintegrateillnesstrajectoryandit'simpactontheirlives.-Willcontinuetoliaisewithunitsocialwork/CMandJTCCpsychosocialstafftoensurecommunicationofgoals&preferences,carecoordinationandcontinuity.-Palliativecareeducationongoing;scopeofpracticeandphilosophydiscussed.Palliativecarecontactinformationgiven
PlanofCare
PALLIATIVECAREPSYCHOSOCIALFOLLOW-UPPreferredlanguage:LanguageUsed:SourcesofInformation:Barrierstoassessment:NoneNextofKin(NOK):***PrimaryCaregiver:OtherContacts:*** ChiefComplaint:Iamfeeling***IntervalHistory:ACP:Assessment:PlanofCare:CoreMeasures: Yes No PalliativeCareEducation X PastoralCare X TherapeuticCounseling X AdvancedCarePlanning X X AssessStress X AssessCoping X AssessAnxiety X AssessAnticipatorygrief X FamilyMeeting X X Bio-ethicsconsult X X PCSInterdisciplinaryRounds X X
Comparisonw/Teamnotes
Differences
* Content* Biopsychosocial
assessment* Interventions
Similarities
* OverallFormat(SOAP)* Integrationofpalliativedomains* ACP* DignityQuestion* CoreMeasures* PlanofCare
Issue Target/Goal Intervention Measurement
AdjustmentCrisis Emotionalregulation
Psycho-education:SFBT
IRS;practitionerobservation/log;“GoldenQuestion”
Mobilizationfordiseasemanagement
CBT IRS;Clientlog
-StableLivingsituation-FamilyFunctioning:wellbeing
-Resourceidentification&referral;collateralcommunication-Familycounseling
Checklist;clientreportFamilyWellbeingLog
Reducedanxiety,increasedperceivedabilitytomanagestress
CBT IRS;Clientsatisfactionmeasure
RemkeTemplateExample
* “FormethecontactinformationforthepatientiskeyduringintegraltimeswhereIneedaquickreferenceguideonwhotocall.”* “Iusethesocialhxasapromptortalkingpointofgettingtoknowthepatientasaperson.”* “Ialwayscheck:ifyoucompletedadvancecareplanningIwouldpullfromthisandcopyandpasteitintomynotetostaycorrelatedwithyours”* “Ilovethatifyoureadournotesfromadmissionthroughdischargeittellsapatient-focusedpalliativecarestory.”
Whatotherteammembersaresaying:
* ThereisnowdoubtthatSWservicesareimportantineffectivehospice&palliativecare* LiteraturespecificallycenteredonoutcomesmeasurementofHPCsocialworkinterventionsissparse* Utilizingatemplatemaysupportmonitoringofoutcomesanddatacollection
OutcomesMeasurement
* What?* Patient/familyprogressre:theirowngoals* Clinicianeffectiveness
* How?* SWAT* PIP* PHQ4orPHQ9* BeckDepressionScale* HospitalDepressionandAnxietyScale(HADS)* CenterforEpidemioligyStudies-Depression(CES-D)Bostonshortform–10items
* GeriatricdepressionScale(shortform)–15items
What/Howdowemeasure?
* Documentqualityimpactsusefulness* Thereisassociationbetweenstructuralcharacteristics(i.e.template)anddocumentquality* UseoftemplatemayenhancecommunicationandcohesionbetweenHPCsocialworkandtheteam* UseoftemplatemayhighlighttheuniquecontributionsofSWinHPC* Canassistwithbetterpatientoutcomesanddatacollection
Conclusion
* TheDignityquestion.(n.d.).RetrivedJan15,2016,fromhttp://dignityincare.ca/en/toolkit.html)
* Bajgier,J.,Bender,J.,Ries,R.(2012)UseofTemplatesforClinicalDocumentationinPsychiatricEvaluations.BeneficialorCounterproductiveforResidentsinTraining?InternationalJournalofPsychiatryinMedicine,43(1):99-103.
* Neri,P.M.,Volk,L.A.,Samaha,S.E.,Williams,D.,Fiskio,J.(2014),Relationshipbetweendocumentationmethodandqualityofchronicdiseasevisitnotes.AppliedClinicalInformatics,5(2):480-90
* Remke,S.(2015).Speakingtheirlanguage:Outcomesforsocialworkpracticeinhospiceandpalliativecare.
* Shen,S.,South,B.,Butler,J.,Barrus,R.,Weir,C.(2012)TheRelationshipBetweenStructuralCharacteristicsof2010ChallengeDocumentsandratingsofDocumentQuality.AMIAAnnualSymposiumProceedings,1012:848-55
References