Patient Discharge Planning Documentation in an Australian Multidisciplinary Rehabilitation Setting Liz Pittman, BA (Hons) RN; Wendy Morton, RN RM DNA; Lynette Edwards, RN RM CRN; Debra Holmes, RN CR/ECN
This article, drawing on data from 17 case studies, addresses problems in documentation of discharge planning in an Australian multidisciplinaryrehabilitation center and the ways these were, or could be, overcome. The problems identified in the case studies were not specific to one discipline; they were due to inadequately dejined guidelines and responsibility and poorly designedforms, and they possibly reflected the tendencyfor members of practice-oriented disciplines to see documentation as low on their list of priorities.
C
oncem that inadequate documentation was resulting in ineffective planning and informal cross-checking by nurses at the time of patient discharge led the authors to undertake case studies of documentation of 17 patients during their stay in an Australian multidisciplinary rehabilitation center to identify areas where improvements could be made.
Literature review Successful discharge planning is a centralized, coordinated multidisciplinary process that ensures that all patients are prepared adequately for discharge and have a plan for continuing care after they leave the hospital. A discharge plan “must be based on a philosophy of patient care that recognizes each patient as an individual, taking into consideration the patient’s emotional, social, and economic history, as well as specific needs for continuing care” (AHA, 1983, p. 2). Discharge planning is, thus, an integral part of care, particularly in rehabilitation settings (Martin, Holt, &Hicks, 1981). The focus of rehabilitation is to enable the patient to return to the community functioning at the optimal level of physical, emotional, psychosocial, and vocational independence. Representatives of various disciplines work together toward the common goal of optimizing patient health and independence (DeVito, 1988). Close consultation between the patient, the family, and the multidisciplinary team identifies the patient’s rehabilitation and posthospital needs and resources. Comprehensive rehabilitation emphasizes both (a) efficiency in the use of time and resources and (b) effectiveness in delivery of services; thus the key words indischarge planning are coordination and communication (AHA, 1983). Responsibility for disseminating information is one that all disciplines share (DeVito, 1988).Regular evaluation of discharge planning is essential, however, to ensure that it is effective. Address correspondence to Liz Pittman,BA (Hons)RN, Coordinator ContinuingEducation,Department ofNursing,La Trobe University, St. Helliers Street, Abbotsford, Victoria 3067, Australia.
The literature deals with many aspects of the discharge process, such as the need for early planning and discharge teams for coordination. Samples of charts (or forms as they are known in Australia) used in various settings often are given (see, for example, DeVito, 1988; Halpert, 1984; Johnson & Pachano, 1981; LaMontagne & McKeehan, 1981; McKeehan, 1981). Despite the fact that accrediting bodies, hospital legal departments, and nursing leaders in the United States have lamented the lack of accurate nursing records (Tapp, 1990), practical problems with discharge documentation have received little attention anywhere.
Discharge planning documentation When a multidisciplinary team is involved in the care of each patient, documentation is a historical record of what was planned, what occurred, and what the outcome was, and is a means of communicating patient progress. It also is a legal requirement, is necessary for professional and economic reasons, and is needed as a source of research data (Griffiths, 1989). For a multidisciplinary team, documentation is the most effective and efficient way of communicating assessments, plans, and goals between disciplines; ensuring that consistent information is given to families and the patient; indicating who has been responsible for assessment, planning, and identification of goals; and , ensuring that members of all disciplines know which plans and actions have been carried out. Good communication among disciplines means that patient/ family problems or potential problems are identified quickly and, if possible, resolved by the appropriate healthcare worker. Among practice-based disciplines committed to a holistic approach, documentation is considered a necessary chore but is low on theorderofprioritiescompared todirectpatientcare(Harris, 1979; Tapp, 1990; Vasey, 1979). Problems are compounded by the multiplicity of forms required to document each patient’s hospital stay, all of which take up the clinician’s time. In a study Vol. 17, No. 6mehabilitation Nursing/Nov-Dec 1992/327
Discharge Planning Documentation
undertaken at The Ohio State Hospital, for example, nurses on medical, surgical, and critical care units spent an average of 73 minutes per 8-hour shift on documentation (Deane, McElroy, & Alden, 1986). Time consumed is only one of the factors involved; “redundancy of forms, repetitive data records, imprecise language contributed to a lack of accurate documentation” in another study (Tapp, 1990,p. 239). Yet adequate documentation is one of the keys to effective discharge planning (Griffiths, 1989). As a general rule, for legal purposes, if it has not been’ documented, it has not been done (Deane, McElroy, & Alden, 1986; Hershey & Lawrence, 1986). Even if information is communicated verbally because of urgency or importance, it also must be documented in the patient’s medical record (FeutzHarter, 1989). It should be time specific and entered into the permanent medical record as soon as possible (Hershey & Lawrence, 1986). Periodic updating And review of problems is also important (Feutz-Harter, 1989). There are several methods of reporting described in the literature. Discipline-specific reporting forms allow space for each discipline to comment on problems, plans, progress, and outcomes. By contrast, function-specific reporting or charting allows space for any discipline to report on specific functional areas. A benefit of functional reporting is that it reminds each clinician to address all areas for a particular patient. Another function-specific method is focus reporting, which employs a detailed checklist within each functional area, including items such as physical abilities or activities of daily living (Griffiths, 1989). A variant of focus reporting refers to charting in a four-column format. The first column is labeled “Focus” (to communicate problems, patient concerns and behaviors, symptoms, and activities); “Data,” “Action,” and “Response”co1umns are used for recording information, actions, and outcomes. The advantage of focus reporting is that the relationship among patient status, healthcare worker actions, and patient outcomes is recognized in the reporting (Lampe, 1989). Regardless of the method used, reports of team meetings should include those attending, recommendations, actions, and those who will follow through on the recommendations. The current status of previous problems and a time frame for resolution should be noted (Maloof, 1986). Designating responsibility for documentation to a team member is important. This article addresses the problems found in documentation and the ways in which these have been overcome in.an Australian facility or could be overcome in any facility. The study The rehabilitation center where the study was camed out is a 102-bed facility in Melbourne, Australia, that recently merged with a 466-bed acute general hospital in an adjacent suburb. It provides a comprehensive medical rehabilitation program as defined by the American Hospital Association (1983). Rehabilitation programs are provided to people with a range of disabilities associated with head injuries, strokes and various other neurological conditions, orthopedic and arthritic conditions, and amputations.
At the center, discharge planning is the responsibility .of the multidisciplinary team. In most Australian healthcare agencies, it is not usual to have a designated person responsible fordischarge planning, although a few acute care hospitals have appointed discharge planning nurses (Colburn, 1990). The center’s multidisciplinary teams include a medical consultant, a primary nurse, aphysiotherapist, an occupational therapist, a social worker, a psychologist, a neuropsychologist, a speech pathologist, and a leisure coordinator, but this may vary slightly depending on the disability of the patient concerned. The team meets to review each patient’s progress at regular case conferences. In addition, family meetings are held at which members of the team, the patient, and the patient’s family discuss the rehabilitation and discharge plan and any problems or potential problems that might need to be resolved. Key events in the rehabilitation process are admission, case conferences, family meetings, home assessment visits, liaison with community services, and discharge. When a home visit has been completed by a team member and the environment is found to be suitable (or has been specially adapted), the patients who are able to cope may go home on weekend leave. This also is regarded as one of the key events in the patient’s progress toward discharge. Documentation guidelines and forms The centerrecently has developed adischarge policy document and guidelines for team case conferences and family meetings. The guidelines for case conferences indicate that a discharge date should be estimated at the first conference following admission. Documentation forms constituting the patient’s medical record include the following: 1. patient registration forms, 2. nursing care plans, 3. history and examination forms, 4. nursing histories, 5. total care progress notes, 6. nursing transfer/discharge summaries, 7. psychological services department forms, 8. occupational therapy reports, 9. case conference report and action sheets, 10. social work reports, 1 1. final discharge summaries, 12. speech pathology reports, and 13. physiotherapy reports. Discipline-specific reporting is used for all documentation involving more than one discipline. Study design The case studies involved analyses of the documented communications in each patient’s medical record. The framework for analysis encompassed the key events occurring during a patient’s stay at the center and included all items in which information on these events would be found. A listing of the key events and the relevant documents appears in Table 1. The questions addressed in the analysis of the documentation for each case were as follows:
328/Nov-Dec 1992Eehabilitation Nursinflol. 17, No. 6
Were assessments, plans, goals, and actions for each patient recorded on the appropriate document and did the information meet with the center’s guidelines? Was there evidence that documented problems and actions were followed up? Did the documentation adequately reflect the key event and the person who was responsible for reporting? Was the recorded material adequate enough to ensure that consistent information could be given to patients and families?
Table 1. Key Events and the Relevant Documents Key Event
Relevant Document
Admission
Nursing history and nursing care plan History and examination form Case conference report and action sheet Reports from each discipline Social work and occupational therapy reports Nursing and various other disciplines’ reports Nursing and social work reports Discharge summary, nursing transfer/ discharge summary
Case conferences Formal family meetings Home/hostel assessment visits Weekend leave Working with community services Discharge
Was the design of the forms used at the center appropriate? Were the guidelines for discharge planning documentation appropriate?
Data collection and analysis Data collection sheets were designed to record the date of each key event, the information given, where it was recorded (or where the information normally would be found if it was missing) and whether thedocumentation oftheevent conformed to thecenter’s guidelines. The 17 case studies were collected over the final 6 months of 1989,concurrent witheachpatient’s hospita1stay.Thecaseswere selected at random by asking a nurse who was not involved in the study to select a bed number, and then that patient’s records were included in the study. A content analysis of the recorded information was camed out to identify problems and suggested actions and to determine whether these were documented subsequently as having been followed through. Where case conferences and formal family meetings were concerned, data were analyzed in relation to the
center’s guidelines for documenting these key events. The two sets of guidelines and the documentation forms then were reviewed in light of the findings of the analysis.
Patients’ profiles Patient diagnoses fell into two broad categories: disabilities resulting from orthopedic or arthritic conditions (7 cases) and diSabilitiesresultingfromheadinjuries( lO).Theaverageagewas 52.2 years with a range from 20 to 87 years (the average age of patients at the center during 1989 was 50.75 years). The average lengthof stay ofpatient sin thestudy was56daysandrangedfrom 15 to 152days. This was longer than the center’s average length of stay (35 days) for patients during 1989. Findings The findings are summarized below: Guidelines were unrealistic in their requirement to set an early discharge date. Responsibility for documenting was not always delegated. The amount of information given varied considerably for two key events, namely, case conferences and family meetings. Forms were poorly designed in some cases. There was a lack of evidence of follow-through on identified problems. The documentation did not always reflect the multidisciplinary nature of the event. Unrealistic guidelines: The discharge policy guidelines required a time frame for discharge to be set at the first case conference after admission, yet an estimated discharge date was documented in only two cases. One of the problems was that the guidelines for discharge planning were not realistic in this respect. For most patients, an estimated discharge date could not be made until later in the rehabilitation process (acknowledged in personal correspondence with the senior specialist in rehabilitation medicine). Varied amounts of information and designated responsibility: As a general observation, when documentation of an event was related to the actions of a single discipline, there were relatively few missing data and little inadequate reporting. Problems most often were found in situations in which a number of disciplines were involved-that is, in reports of case conferences and family meetings. This suggested that responsibility for documentation had not been designated clearly. Where case conferences were Concerned, the responsibility for keeping records fell to the resident medipal officer or registrar, each of whom is part of the hospital staff for only a limited time (3 months and 6 months, respectively). The amount of information recorded varied considerably according to the individual medical officer and sometimes reflected only medical problems rather than the team nature of the conference or those present. Thus, if a member of the disciplinary team needed to rely on case conference documentation to ensure that consistent information was given to patients and families, it would not have been adequate in some cases. As case conference guidelines state that
Vol. 17, No. 6mehabilitation Nursing/Nov-Dec 1992/329
Discharge Planning Documentation
all assessments, progress notes, and management plans should be documented, it was concluded that the guidelines were not sufficiently specific about the way in which this should be done. In the case of family meetings, the responsibility for documentation was not formally designated and reporting was extremely variable. At the time of the study, there was not a separate form designated for this purpose, although there was a recommendation in the family meeting guidelines that outcomes be discussed at case conferences and that plans be recorded. This occurred in only three of thecases, and the information could be gleaned only from individual discipline reports in other instances. In five of the 17 case studies, the reports included no information on- who attended the family meeting or the matters discussed. Form design and lack of follow-up: Content analysis of the case conference report and action sheets revealed that in eight of the case studies, problems identified or actions suggested (considered important enough to be recorded at the time) had no documentedfollow-up. Areview ofthe sheetsrevealed aproblem in the design that contributed to this lack of information. As noted, the type of reporting used at the center was discipline specific, with each discipline being allocated space across the case conference report and action sheet. Columns across the page were labeled “ProblemsProgress,” “Goals,” and “Action.” In effect, space was allocated for information to be recorded in a box. It was found that where information was required to be placed in boxes, there was a tendency to write straight across the boxes that were designed for other pieces of information. Often no room was left to indicate whether the problems identified at the case conference had been followed up or not. The normal writing pattern is to write straight across the page; therefore, forms and charts should reflect this, where practical. If boxes are used, they should be reserved for check marks or very short answers like “yes” or “no.” Because the hospital discharge policy document emphasized the importance of setting discharge planning goals shortly after admission, the nursing history documents were examined. While it already has been noted that to set an actual discharge date at this point is unrealistic for most patients, theneed todevelop plans and goals in the rehabilitation process is not obviated. In six of the 17 case studies, discharge planning was not documented on the nursing history or the nursing care plan forms. Examination revealed that an appropriate section for this purpose had not been provided on either of the forms, and this may have contributed to the lack of documentation. These findings indicated a lack of documented information of two of the key events in the rehabilitation process, which could seriously affect the consistency of information given to family members. The lack of a central location for the information suggested that information flow between disciplines could be affected and could have been one of the factors contributing to the perception by nursing staff that a great deal of informal crosschecking of information took place. Recommendations and implementation Recommendation 1: Case conference guidelines should be reviewed to indicate a more realistic time period for the setting of
a discharge date after patient admission, and responsibility for documentation should be clearly designated. Implementation: The case conference guidelines were reviewed by the rehabilitation program committee of the center. Recommendation 2: The case conference report and action sheet should be redesigned. Implementation: This form has been redesigned to follow normal writing patterns, incorporating a function-based (previously discipline-based) reporting system, and is now officially part of each patient’s medical history. Both the multidisciplinary approach to case conferences and the relationship between patient status and outcomes and team member’s actions are now emphasized by the reporting method. Recommendation 3: An adequate recording procedure should be devised for family meetings and the responsibility designated to a member of the team. Implementation:A procedure has been developed and tried on one ward. As copies are to be given to both the family and the patient, it was decided not to design an official form. Instead, the social worker collates the report of each member of the multidisciplinary team on the center’s letterhead; copies of this are given to the patient and to the family, and one is kept on the ward. Recommendation 4: The nursing audit committee should review nursing history forms with a view to including a section specifically for discharge planning. Implementation:This recommendation has been accepted and a discharge planning section included. Conclusion The documentation problems identified were not discipline specific in most cases; they occurred primarily because of a lack of clear guidelines, a lack of defined responsibility, and inadequately designed forms. They probably reflected the tendency for practice-oriented disciplines to see documentation as a low priority. Compliance with guidelines is best served when the guidelines reflect what actually is achievable in the majority of circumstances. Information will not be documented if there is not a convenient, specifically allocated place to put it. Neither will multidisciplinary meetings about patients’ progress be recorded if the responsibility to do so has not been designated. Once documentation problems are identified, solutions can be found relatively easily, as the examples given have shown. Addressing these problems at the level of documentation, although an essential step, may be only a partial answer, however. Documentation still may be perceived to be a chore rather than a formal and necessary means of communication across disciplines. Nevertheless, the very process of implementing recommended changes through healthcare agency committees does, in itself, serve to emphasize the importance of this form of communication. Liz Pittman is the coordinator of continuing education in the department of nursing at La Trobe University in Melbourne, Australia. Wendy Morton is the assistant director of nursing and Lynette Edwards and Debra Holmes are patient care coordina-
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tors at Austin Hospital-Royal Talbot Rehabilitation Centre in Melbourne, Australia.
References American Hospital Association (AHA). (1983). Introduction to discharge planning for hospitals. Chicago, 1L: American Hospital Publishing, Inc. Colburn, H. (1990, October). The early discharge program at St. George's Hospital, Sydney, NSW. Paper given at the Seminar on Discharge Planning, Health Department, Victoria, Australia. Deane, D., McElroy, M.J., & Alden, S. (1986). Documentation: Meeting requirements while maximizing productivity. Nursing Economics, 4(4), 174-178. DeVito, A.J. (1 988). Documenting client education in rehabilitation: An interdisciplinary approach. Rehabilitation Nursing, 13,26-28. Feutz-Harter, S . (1989). Documentation principles and pitfalls. Journal of Nursing Administration, 19( 12), 7-9. Griffiths, A. (1989). Focus charting in rehabilitation. Rehabilitafion Nursing, 14, 142-148. Halpert, M. ( 1984, July). Data integrity through effective forms design. Journal of American Records Association, pp. 33-38. Harris, R.B. (1979). A strong vote for nursing process. American Journal of Nursing, 79, 1999-2001. Hershey, N., & Lawrence, R. (1986). The influence of charting in liability determination. Journal of Nursing Administration, 16, 35-37. Johnson, J., & Pachano, A. (1981). Planning patients' discharge. Supervisor Nurse, 12(44), 44-48. LaMontagne, M.E., & McKeehan, K.M. (1981). Hospital administration views discharge planning. In K.M. McKeehan (Ed.), Continuing care: A rnrrltidisciplinary approach to discharge planning (pp. 3-17). St Louis: The C.V. Mosby Company. Lampe, S.S. (1989). Nursing documentation: A new perspective. Nurse Educator, 14(4) 13, 16. Maloof, M. (1986). Preparing for agency accreditation. Rehabilitation Nursing, 11(5), 11-12. Martin, N., Holt, N.B., & Hicks, D. (Eds.). (1981). Comprehensive rehabilitation nursing. New York: McGraw Hill Book Company. McKeehan, K.M. (198 1). Conceptual framework for discharge planning. In K.M. McKeehan (Ed.), Continuing care: A multidisciplinary approach to dischargeplanning (pp. 3-17). St. Louis: The C.V. Mosby Company. Tapp, R.A. (1990). Inhibitors and facilitators to documentation of nursing practice. Western Journal of Nursing Research, 12(2), 229-240. Vasey, E.K. (1979). Writing your patient's care plan efficiently. Nursing, 9(4), 67-7 1.
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Vol. 17, No. b/Rehabilitation Nursing/Nov-Dec 1992/331
This article, drawing on data from 17 case studies, addresses problems in documentation of discharge planning in an Australian multidisciplinaryrehabilitation center and the ways these were, or could be, overcome. The problems identified in the case studies were not specific to one discipline; they were due to inadequately dejined guidelines and responsibility and poorly designedforms, and they possibly reflected the tendencyfor members of practice-oriented disciplines to see documentation as low on their list of priorities.
C
oncem that inadequate documentation was resulting in ineffective planning and informal cross-checking by nurses at the time of patient discharge led the authors to undertake case studies of documentation of 17 patients during their stay in an Australian multidisciplinary rehabilitation center to identify areas where improvements could be made.
Literature review Successful discharge planning is a centralized, coordinated multidisciplinary process that ensures that all patients are prepared adequately for discharge and have a plan for continuing care after they leave the hospital. A discharge plan “must be based on a philosophy of patient care that recognizes each patient as an individual, taking into consideration the patient’s emotional, social, and economic history, as well as specific needs for continuing care” (AHA, 1983, p. 2). Discharge planning is, thus, an integral part of care, particularly in rehabilitation settings (Martin, Holt, &Hicks, 1981). The focus of rehabilitation is to enable the patient to return to the community functioning at the optimal level of physical, emotional, psychosocial, and vocational independence. Representatives of various disciplines work together toward the common goal of optimizing patient health and independence (DeVito, 1988). Close consultation between the patient, the family, and the multidisciplinary team identifies the patient’s rehabilitation and posthospital needs and resources. Comprehensive rehabilitation emphasizes both (a) efficiency in the use of time and resources and (b) effectiveness in delivery of services; thus the key words indischarge planning are coordination and communication (AHA, 1983). Responsibility for disseminating information is one that all disciplines share (DeVito, 1988).Regular evaluation of discharge planning is essential, however, to ensure that it is effective. Address correspondence to Liz Pittman,BA (Hons)RN, Coordinator ContinuingEducation,Department ofNursing,La Trobe University, St. Helliers Street, Abbotsford, Victoria 3067, Australia.
The literature deals with many aspects of the discharge process, such as the need for early planning and discharge teams for coordination. Samples of charts (or forms as they are known in Australia) used in various settings often are given (see, for example, DeVito, 1988; Halpert, 1984; Johnson & Pachano, 1981; LaMontagne & McKeehan, 1981; McKeehan, 1981). Despite the fact that accrediting bodies, hospital legal departments, and nursing leaders in the United States have lamented the lack of accurate nursing records (Tapp, 1990), practical problems with discharge documentation have received little attention anywhere.
Discharge planning documentation When a multidisciplinary team is involved in the care of each patient, documentation is a historical record of what was planned, what occurred, and what the outcome was, and is a means of communicating patient progress. It also is a legal requirement, is necessary for professional and economic reasons, and is needed as a source of research data (Griffiths, 1989). For a multidisciplinary team, documentation is the most effective and efficient way of communicating assessments, plans, and goals between disciplines; ensuring that consistent information is given to families and the patient; indicating who has been responsible for assessment, planning, and identification of goals; and , ensuring that members of all disciplines know which plans and actions have been carried out. Good communication among disciplines means that patient/ family problems or potential problems are identified quickly and, if possible, resolved by the appropriate healthcare worker. Among practice-based disciplines committed to a holistic approach, documentation is considered a necessary chore but is low on theorderofprioritiescompared todirectpatientcare(Harris, 1979; Tapp, 1990; Vasey, 1979). Problems are compounded by the multiplicity of forms required to document each patient’s hospital stay, all of which take up the clinician’s time. In a study Vol. 17, No. 6mehabilitation Nursing/Nov-Dec 1992/327
Discharge Planning Documentation
undertaken at The Ohio State Hospital, for example, nurses on medical, surgical, and critical care units spent an average of 73 minutes per 8-hour shift on documentation (Deane, McElroy, & Alden, 1986). Time consumed is only one of the factors involved; “redundancy of forms, repetitive data records, imprecise language contributed to a lack of accurate documentation” in another study (Tapp, 1990,p. 239). Yet adequate documentation is one of the keys to effective discharge planning (Griffiths, 1989). As a general rule, for legal purposes, if it has not been’ documented, it has not been done (Deane, McElroy, & Alden, 1986; Hershey & Lawrence, 1986). Even if information is communicated verbally because of urgency or importance, it also must be documented in the patient’s medical record (FeutzHarter, 1989). It should be time specific and entered into the permanent medical record as soon as possible (Hershey & Lawrence, 1986). Periodic updating And review of problems is also important (Feutz-Harter, 1989). There are several methods of reporting described in the literature. Discipline-specific reporting forms allow space for each discipline to comment on problems, plans, progress, and outcomes. By contrast, function-specific reporting or charting allows space for any discipline to report on specific functional areas. A benefit of functional reporting is that it reminds each clinician to address all areas for a particular patient. Another function-specific method is focus reporting, which employs a detailed checklist within each functional area, including items such as physical abilities or activities of daily living (Griffiths, 1989). A variant of focus reporting refers to charting in a four-column format. The first column is labeled “Focus” (to communicate problems, patient concerns and behaviors, symptoms, and activities); “Data,” “Action,” and “Response”co1umns are used for recording information, actions, and outcomes. The advantage of focus reporting is that the relationship among patient status, healthcare worker actions, and patient outcomes is recognized in the reporting (Lampe, 1989). Regardless of the method used, reports of team meetings should include those attending, recommendations, actions, and those who will follow through on the recommendations. The current status of previous problems and a time frame for resolution should be noted (Maloof, 1986). Designating responsibility for documentation to a team member is important. This article addresses the problems found in documentation and the ways in which these have been overcome in.an Australian facility or could be overcome in any facility. The study The rehabilitation center where the study was camed out is a 102-bed facility in Melbourne, Australia, that recently merged with a 466-bed acute general hospital in an adjacent suburb. It provides a comprehensive medical rehabilitation program as defined by the American Hospital Association (1983). Rehabilitation programs are provided to people with a range of disabilities associated with head injuries, strokes and various other neurological conditions, orthopedic and arthritic conditions, and amputations.
At the center, discharge planning is the responsibility .of the multidisciplinary team. In most Australian healthcare agencies, it is not usual to have a designated person responsible fordischarge planning, although a few acute care hospitals have appointed discharge planning nurses (Colburn, 1990). The center’s multidisciplinary teams include a medical consultant, a primary nurse, aphysiotherapist, an occupational therapist, a social worker, a psychologist, a neuropsychologist, a speech pathologist, and a leisure coordinator, but this may vary slightly depending on the disability of the patient concerned. The team meets to review each patient’s progress at regular case conferences. In addition, family meetings are held at which members of the team, the patient, and the patient’s family discuss the rehabilitation and discharge plan and any problems or potential problems that might need to be resolved. Key events in the rehabilitation process are admission, case conferences, family meetings, home assessment visits, liaison with community services, and discharge. When a home visit has been completed by a team member and the environment is found to be suitable (or has been specially adapted), the patients who are able to cope may go home on weekend leave. This also is regarded as one of the key events in the patient’s progress toward discharge. Documentation guidelines and forms The centerrecently has developed adischarge policy document and guidelines for team case conferences and family meetings. The guidelines for case conferences indicate that a discharge date should be estimated at the first conference following admission. Documentation forms constituting the patient’s medical record include the following: 1. patient registration forms, 2. nursing care plans, 3. history and examination forms, 4. nursing histories, 5. total care progress notes, 6. nursing transfer/discharge summaries, 7. psychological services department forms, 8. occupational therapy reports, 9. case conference report and action sheets, 10. social work reports, 1 1. final discharge summaries, 12. speech pathology reports, and 13. physiotherapy reports. Discipline-specific reporting is used for all documentation involving more than one discipline. Study design The case studies involved analyses of the documented communications in each patient’s medical record. The framework for analysis encompassed the key events occurring during a patient’s stay at the center and included all items in which information on these events would be found. A listing of the key events and the relevant documents appears in Table 1. The questions addressed in the analysis of the documentation for each case were as follows:
328/Nov-Dec 1992Eehabilitation Nursinflol. 17, No. 6
Were assessments, plans, goals, and actions for each patient recorded on the appropriate document and did the information meet with the center’s guidelines? Was there evidence that documented problems and actions were followed up? Did the documentation adequately reflect the key event and the person who was responsible for reporting? Was the recorded material adequate enough to ensure that consistent information could be given to patients and families?
Table 1. Key Events and the Relevant Documents Key Event
Relevant Document
Admission
Nursing history and nursing care plan History and examination form Case conference report and action sheet Reports from each discipline Social work and occupational therapy reports Nursing and various other disciplines’ reports Nursing and social work reports Discharge summary, nursing transfer/ discharge summary
Case conferences Formal family meetings Home/hostel assessment visits Weekend leave Working with community services Discharge
Was the design of the forms used at the center appropriate? Were the guidelines for discharge planning documentation appropriate?
Data collection and analysis Data collection sheets were designed to record the date of each key event, the information given, where it was recorded (or where the information normally would be found if it was missing) and whether thedocumentation oftheevent conformed to thecenter’s guidelines. The 17 case studies were collected over the final 6 months of 1989,concurrent witheachpatient’s hospita1stay.Thecaseswere selected at random by asking a nurse who was not involved in the study to select a bed number, and then that patient’s records were included in the study. A content analysis of the recorded information was camed out to identify problems and suggested actions and to determine whether these were documented subsequently as having been followed through. Where case conferences and formal family meetings were concerned, data were analyzed in relation to the
center’s guidelines for documenting these key events. The two sets of guidelines and the documentation forms then were reviewed in light of the findings of the analysis.
Patients’ profiles Patient diagnoses fell into two broad categories: disabilities resulting from orthopedic or arthritic conditions (7 cases) and diSabilitiesresultingfromheadinjuries( lO).Theaverageagewas 52.2 years with a range from 20 to 87 years (the average age of patients at the center during 1989 was 50.75 years). The average lengthof stay ofpatient sin thestudy was56daysandrangedfrom 15 to 152days. This was longer than the center’s average length of stay (35 days) for patients during 1989. Findings The findings are summarized below: Guidelines were unrealistic in their requirement to set an early discharge date. Responsibility for documenting was not always delegated. The amount of information given varied considerably for two key events, namely, case conferences and family meetings. Forms were poorly designed in some cases. There was a lack of evidence of follow-through on identified problems. The documentation did not always reflect the multidisciplinary nature of the event. Unrealistic guidelines: The discharge policy guidelines required a time frame for discharge to be set at the first case conference after admission, yet an estimated discharge date was documented in only two cases. One of the problems was that the guidelines for discharge planning were not realistic in this respect. For most patients, an estimated discharge date could not be made until later in the rehabilitation process (acknowledged in personal correspondence with the senior specialist in rehabilitation medicine). Varied amounts of information and designated responsibility: As a general observation, when documentation of an event was related to the actions of a single discipline, there were relatively few missing data and little inadequate reporting. Problems most often were found in situations in which a number of disciplines were involved-that is, in reports of case conferences and family meetings. This suggested that responsibility for documentation had not been designated clearly. Where case conferences were Concerned, the responsibility for keeping records fell to the resident medipal officer or registrar, each of whom is part of the hospital staff for only a limited time (3 months and 6 months, respectively). The amount of information recorded varied considerably according to the individual medical officer and sometimes reflected only medical problems rather than the team nature of the conference or those present. Thus, if a member of the disciplinary team needed to rely on case conference documentation to ensure that consistent information was given to patients and families, it would not have been adequate in some cases. As case conference guidelines state that
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Discharge Planning Documentation
all assessments, progress notes, and management plans should be documented, it was concluded that the guidelines were not sufficiently specific about the way in which this should be done. In the case of family meetings, the responsibility for documentation was not formally designated and reporting was extremely variable. At the time of the study, there was not a separate form designated for this purpose, although there was a recommendation in the family meeting guidelines that outcomes be discussed at case conferences and that plans be recorded. This occurred in only three of thecases, and the information could be gleaned only from individual discipline reports in other instances. In five of the 17 case studies, the reports included no information on- who attended the family meeting or the matters discussed. Form design and lack of follow-up: Content analysis of the case conference report and action sheets revealed that in eight of the case studies, problems identified or actions suggested (considered important enough to be recorded at the time) had no documentedfollow-up. Areview ofthe sheetsrevealed aproblem in the design that contributed to this lack of information. As noted, the type of reporting used at the center was discipline specific, with each discipline being allocated space across the case conference report and action sheet. Columns across the page were labeled “ProblemsProgress,” “Goals,” and “Action.” In effect, space was allocated for information to be recorded in a box. It was found that where information was required to be placed in boxes, there was a tendency to write straight across the boxes that were designed for other pieces of information. Often no room was left to indicate whether the problems identified at the case conference had been followed up or not. The normal writing pattern is to write straight across the page; therefore, forms and charts should reflect this, where practical. If boxes are used, they should be reserved for check marks or very short answers like “yes” or “no.” Because the hospital discharge policy document emphasized the importance of setting discharge planning goals shortly after admission, the nursing history documents were examined. While it already has been noted that to set an actual discharge date at this point is unrealistic for most patients, theneed todevelop plans and goals in the rehabilitation process is not obviated. In six of the 17 case studies, discharge planning was not documented on the nursing history or the nursing care plan forms. Examination revealed that an appropriate section for this purpose had not been provided on either of the forms, and this may have contributed to the lack of documentation. These findings indicated a lack of documented information of two of the key events in the rehabilitation process, which could seriously affect the consistency of information given to family members. The lack of a central location for the information suggested that information flow between disciplines could be affected and could have been one of the factors contributing to the perception by nursing staff that a great deal of informal crosschecking of information took place. Recommendations and implementation Recommendation 1: Case conference guidelines should be reviewed to indicate a more realistic time period for the setting of
a discharge date after patient admission, and responsibility for documentation should be clearly designated. Implementation: The case conference guidelines were reviewed by the rehabilitation program committee of the center. Recommendation 2: The case conference report and action sheet should be redesigned. Implementation: This form has been redesigned to follow normal writing patterns, incorporating a function-based (previously discipline-based) reporting system, and is now officially part of each patient’s medical history. Both the multidisciplinary approach to case conferences and the relationship between patient status and outcomes and team member’s actions are now emphasized by the reporting method. Recommendation 3: An adequate recording procedure should be devised for family meetings and the responsibility designated to a member of the team. Implementation:A procedure has been developed and tried on one ward. As copies are to be given to both the family and the patient, it was decided not to design an official form. Instead, the social worker collates the report of each member of the multidisciplinary team on the center’s letterhead; copies of this are given to the patient and to the family, and one is kept on the ward. Recommendation 4: The nursing audit committee should review nursing history forms with a view to including a section specifically for discharge planning. Implementation:This recommendation has been accepted and a discharge planning section included. Conclusion The documentation problems identified were not discipline specific in most cases; they occurred primarily because of a lack of clear guidelines, a lack of defined responsibility, and inadequately designed forms. They probably reflected the tendency for practice-oriented disciplines to see documentation as a low priority. Compliance with guidelines is best served when the guidelines reflect what actually is achievable in the majority of circumstances. Information will not be documented if there is not a convenient, specifically allocated place to put it. Neither will multidisciplinary meetings about patients’ progress be recorded if the responsibility to do so has not been designated. Once documentation problems are identified, solutions can be found relatively easily, as the examples given have shown. Addressing these problems at the level of documentation, although an essential step, may be only a partial answer, however. Documentation still may be perceived to be a chore rather than a formal and necessary means of communication across disciplines. Nevertheless, the very process of implementing recommended changes through healthcare agency committees does, in itself, serve to emphasize the importance of this form of communication. Liz Pittman is the coordinator of continuing education in the department of nursing at La Trobe University in Melbourne, Australia. Wendy Morton is the assistant director of nursing and Lynette Edwards and Debra Holmes are patient care coordina-
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tors at Austin Hospital-Royal Talbot Rehabilitation Centre in Melbourne, Australia.
References American Hospital Association (AHA). (1983). Introduction to discharge planning for hospitals. Chicago, 1L: American Hospital Publishing, Inc. Colburn, H. (1990, October). The early discharge program at St. George's Hospital, Sydney, NSW. Paper given at the Seminar on Discharge Planning, Health Department, Victoria, Australia. Deane, D., McElroy, M.J., & Alden, S. (1986). Documentation: Meeting requirements while maximizing productivity. Nursing Economics, 4(4), 174-178. DeVito, A.J. (1 988). Documenting client education in rehabilitation: An interdisciplinary approach. Rehabilitation Nursing, 13,26-28. Feutz-Harter, S . (1989). Documentation principles and pitfalls. Journal of Nursing Administration, 19( 12), 7-9. Griffiths, A. (1989). Focus charting in rehabilitation. Rehabilitafion Nursing, 14, 142-148. Halpert, M. ( 1984, July). Data integrity through effective forms design. Journal of American Records Association, pp. 33-38. Harris, R.B. (1979). A strong vote for nursing process. American Journal of Nursing, 79, 1999-2001. Hershey, N., & Lawrence, R. (1986). The influence of charting in liability determination. Journal of Nursing Administration, 16, 35-37. Johnson, J., & Pachano, A. (1981). Planning patients' discharge. Supervisor Nurse, 12(44), 44-48. LaMontagne, M.E., & McKeehan, K.M. (1981). Hospital administration views discharge planning. In K.M. McKeehan (Ed.), Continuing care: A rnrrltidisciplinary approach to discharge planning (pp. 3-17). St Louis: The C.V. Mosby Company. Lampe, S.S. (1989). Nursing documentation: A new perspective. Nurse Educator, 14(4) 13, 16. Maloof, M. (1986). Preparing for agency accreditation. Rehabilitation Nursing, 11(5), 11-12. Martin, N., Holt, N.B., & Hicks, D. (Eds.). (1981). Comprehensive rehabilitation nursing. New York: McGraw Hill Book Company. McKeehan, K.M. (198 1). Conceptual framework for discharge planning. In K.M. McKeehan (Ed.), Continuing care: A multidisciplinary approach to dischargeplanning (pp. 3-17). St. Louis: The C.V. Mosby Company. Tapp, R.A. (1990). Inhibitors and facilitators to documentation of nursing practice. Western Journal of Nursing Research, 12(2), 229-240. Vasey, E.K. (1979). Writing your patient's care plan efficiently. Nursing, 9(4), 67-7 1.
m o w in the final stages of completion, Flower Memorial Hospital's new 45&d rehabilitationcenter will combine a state-ofthe-art setting with a transdisciplinary approach to patient care The resulting environment will offer unique advantages for both patients and professionals. Offering a comprehensive range of rehab services, including S.C. Injury, Sports Injury, Multiple Trauma Injury, Neurolwical disabiiitiesand more, our new center provides exceptional promise for potential. Share in our exciting future by joining us in one of the following positions:
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In its thirty plus years, Holy Cross Hospital has grown from a general 100-bed hospital to a 567-bed center for health care that embraces virtually every specialty. In our newly renovated, in-house, 43-bed CARF accredited Rehabilitation Unit, you will find a multidisciplinary team approach and the ultimate environment for offering the finest patient care. Reporting to the Unit Director, the Senior Nurse will be responsible for the overall night shift operation of the Unit. The individual we seek must be a Florida licensed (or eligible) RN with a minimum of 2 years rehab experience and a charge background. Holy Cross offers excellent salary and comprehensive benefits including tuition reimbursement, on-site child care and wellness/fitness center. For information, call Maria Ferrante collect at (305) 776-3086. Human Resources, Holy Cross Hospital, 4725 N. Federal Highway, Ft. Lauderdale, FL 33308. Equal Opportunity Employer.
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Holy Cross Hospital Under the direction 01 the Sisters 01 Mercy
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