Outcome Identification and Planning
Sample desired outcomes include the following:
- Appropriate treatments, medications, and other care measures and support consistent with plan of care are received as scheduled or needed.
- All applicable care providers and payer sources will have accurate information concerning the client and any changes in client condition.
Special Considerations in Planning and Implementation
Under the Health Insurance Portability and Accountability Act, client privacy must be maintained through all reasonable means, whether verbal or written. Verbal and written communication must be confined to the appropriate settings and appropriate individuals as necessary to facilitate client care, as violations of protection of the client's privacy could result in criminal or civil litigation. When "walking rounds" are employed, verbal information about the client should be shared in a more private setting (e.g., in a report room) before going to the client's room for visual verification of or supplemental information on the client's condition.
When reporting to caregivers with little previous exposure to the client, more background may be needed or desired. Caregivers with extensive previous exposure to the client may require only a brief update of pertinent changes. Take a few minutes to determine exactly what information is needed (e.g., a medical supply company about to make a delivery will need a correct address; a payer source will need to know client condition, care being received, and expected duration of care). Remember to report data or occurrences from previous shifts, days, or visits, when pertinent. Include concerns of the client, family members, or significant others. Establish with the agency a method for routing information received from the doctor's office. In some agencies, the field nurse is called directly by pager or by cellular phone, whereas in others the supervisor is the go-between. All parties involved in the communication must have the same information.
Reports on dying clients should remain focused on providing optimal care to facilitate a peaceful death for the client and to provide support to the family/significant others as needed.
The assessment and report of a homebound client should include the client's status at the time of the last home health visit, the client's response to interventions, any restrictions present in the environment (e.g., no running water, no electricity), and any adaptations that have been made in client-care procedures (e.g., irrigating a wound while in the bathtub). The visit report should also include the client's address (with directions if the home is difficult to locate), any special supplies or equipment to be taken on the next visit, and client teaching needs. It is rare that the home health nurse will speak directly with the doctor during doctor office hours. Establish a contact at the office who will reliably transfer information to the doctor. Check with the office to determine the best time and method (e.g., telephone, fax, e-mail) to leave nonemergency messages for the doctor.
Transcultural Pertinent data about the client's sociocultural background should be included if the data are significant to some aspect of the client's care.
Cost-Cutting Tip Tape-recording reports may be less time-consuming and therefore more cost-effective, but follow agency guidelines to avoid violating client privacy. If interdisciplinary shift reports are not a standard daily routine, a periodic interdisciplinary conference may prevent unnecessary resource utilization due to duplications from various service departments.
Direct communication ensures the greatest accuracy of information exchange. However, if information must be relayed to the doctor, another member of the health care team, a payer, or the client through a third party, the nurse should follow up as soon as possible to validate that the correct information was relayed. Reports should never be delegated to unlicensed personnel. As a clinical nursing student, remember that reports should be given only to licensed personnel or the instructor before leaving your unit.