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NURSING DISCHARGE SUMMARY 315.pdf - COALINGA STATE HOSPITAL

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NURSING DISCHARGE SUMMARY 315.pdf - COALINGA STATE HOSPITAL Powered By Docstoc
					                             COALINGA STATE HOSPITAL
                             NURSING POLICY AND PROCEDURE MANUAL
                             SECTION - Nursing Care
                             POLICY NUMBER: 315

                             Effective Date: August 31, 2006


SUBJECT: NURSING DISCHARGE SUMMARY

1. PURPOSE:

  The Nursing Discharge Summary serves as a communication tool between
  Coalinga State Hospital and receiving facilities for promoting continuity of
  care and treatment.

2. POLICY:

  1. The Nursing Discharge Summary “Nursing Discharge Summary shall be
     completed by the RN in timely readiness prior to the Individual leaving.
     The RN shall verbally explain discharge instructions/teaching to the
     Individual. The pink copy of the Discharge Summary will be provided to
     the Individual unless clinically contraindicated.
  2. A Nursing Discharge Summary is to accompany every Individual who is
     discharged from Coalinga State Hospital even for a one-day court visit
     with the following exceptions:
          a. Hearings
          b. Department 95A Conservatorship Hearings
          c. Probate Consrevatorship Hearings
          d. Clinic appointments at outside medical facilities
  3. The yellow copy of the Nursing Discharge Summary will be placed in an
     envelope and given to the Individual’s escort, Correctional Officer, next
     care provider, or family member to hand carry to the accepting facility or
     mental health agency.
  4. If the Individual is going to a continued court hearing a prior “Nursing
     Discharge Summary”, that had been completed within the past 30 days,
     may be photocopied and sent along with the Individual provided there
     have been on changes in the Individuals condition or treatment since the
     summary was last completed. If there are no changes, the Registered
     Nurse shall sign and date the from again and write “NO CHANGE”. The
     unit shall provide a copy of this Nursing Discharge Summary and the
     “Immunization and Communicable Disease Flow Sheet” (MH 5667 Side 1
     and Side 2) to the HSS. If there are any changes in the Individual’s
     condition or treatment, a new Nursing Discharge Summary shall be
     initiated and completed
  5. The Shift Lead will insure this document is completed in a timely manner.



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  6. All sections of the Nursing Discharge Summary are to be addressed. DO
     NOT LEAVE ANY SECTION BLANK. Specify “None”, “N/A”, or “Not
     applicable” as appropriate.
  7. The form is meant to serve as a tool to pass on information that another
     facility or caretaker would need to know to continue in the care for the
     Individual. Present the information in a format that would best facilitate
     this.
  8. A photocopy of the “Immunization and Communicable Disease Flow
     Sheet” (MH 5667 Side 1 and Side 2) shall be attached to the Nursing
     Discharge Summary (MH 5741B).
  9. If the Individual is on Clozaril (Clozapine) a “Clozapine Data” form shall
     also be completed and included in with the Nursing Discharge Summary.
     “Section One” of this form shall be completed by the unit RN. “Section
     Two” shall be completed by the Psychiatrist. A CBC blood level shall be
     drawn as a STAT the day before the Individual is discharged so that the
     results can be included with this discharge packet.
  10. The RN is responsible to insure the document is complete, legible, and
     accurate.
  11. As a Quality Control measure, once the Registered Nurse has completed
     the Nursing Discharge Summary, the nurse shall contact the HSS. The
     HSS shall then review the form for completeness and legibility. If all
     required components are evident, the HSS will sign their full name, title
     and date on the document in the area below the signature of the RN to
     indicate the document is complete and accurate. If components are
     lacking, the HSS will inform the RN to include the required information.
  12. The RN with the assistance of the HSS will make one photocopy of the
     Nursing Discharge Summary, “Immunization and Communicable Disease
     Flow Sheet”, and the “Clozapine Data”form. The RN shall be responsible
     for placing the original documents back into the Individual’s chart.
  13. The Registered Nurse shall be responsible for reviewing the discharge
     instructions with the Individual prior to discharge.

3. GENERAL INFROMATION:

  When preparing the document, the RN is advised to print clearly and legibly.
  Press firmly to insure the information records onto the first (yellow) and
  second (pink) copy of the NCR paper.

  The Nursing Discharge Summary shall contain but not be limited to:

  a. List of all medications, dosages, times of administration, and duration of
  order (including such items as lotrimin crème, magic shave, ect. if these were
  part of the Individual’s treatment orders)
  b. List of all treatments (including topical treatments), times of administration,
  and duration of order




                                       -2-                            N.P.P No. 315
  c. The last date and blood level of labs drawn for all medication levels being
  closely monitored (e.g. lithium, digoxin, tegretol, Phenobarbital, diliantin, ect.).
  Also state when the next blood level is due if applicable.
  d. Identify Individual’s level of cooperation with taking his medication (e.g.
  cooperative, unable/unwilling to take medication, needs prompting, attempts
  to cheek/refuses)
  e. Identify all ALERGIES and ALERTS. Do not leave these sections blank. If
  there are no allergies or alerts write “NO KNOWN ALLERGIES”, “NONE”, or
  “NOT APPLICABLE”
  f. When identifying ALERTS (e.g. Homicidal, Suicidal, Self-Abuse, Assault,
  Arson, AWOL) elaborate all alerts within the Nursing Treatment Summary
  section including the most recent and/or significant dates of this behavior.
  Provide any known precursor or trigger events that may contribute to the
  behavior
  g. Diabetic progress-blood sugar stability, FBS results, frequency of
  fingerstick cheeks and results, insulin sliding scare regimen, diabetic diet,
  Individual teaching, special care needs.
  h.Individuals with a positive PPD should be identified within the ALERT
  section. Elaborate further details within the Nursing Treatment Summary
  section. Include the date of the positive PPD reading, date and clinical
  impression of the last Chest X-Ray, treatment provided, and follow-up
  treatment still required (e.g. list start and stop dates of INH therapy)
  f. Specify diet and nutritional needs
  g. Check pertinent boxes associated with “Ongoing Treatment” elaborating
  further in the summary section as needed
  h. List the DSM IV-R Axis I through IV in the Nursing Treatment Summary
  section. Include the list of all open medical and psychiatric problems including
  progress or regress, nursing interventions, behavioral precautions, brief
  description of the Individual, and brief description of their crime with Penal
  Code and maximum date of commitment, equipment needs, and other
  pertinent continuing care needs
  i. A second (or more) page can be used and labeled “Nursing Discharge
  Summary –Continued” if more space is needed to complete the summary
  than is allowed in the Nursing Treatment Summary section
  j. Describe “Special Instructions” provided to Individual, family, or accepting
  facility. Review the “Wellness and Recovery Individual/Family Heath
  Education Record” to apprise the accepting caretaker or facility of pertinent
  teaching provided to the Individual, and what further follow-up teaching or
  reinforcement may be needed. Emphasize the Individual’s level of
  understanding.




4. PRECAUTIONS:




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The Registered Nurse preparing the Nursing Discharge Summary and
documents will insure that the original documents “Nursing Discharge
Summary”, “Immunization and Communicable Disease Flow Sheet”, and the
“Clozapine Data” form shall remain in the chart. Only a photocopy of these
documents are to be sent to the court or accepting facility.

Since the Nursing Discharge Summary is a form that comes prepared with
NCR paper, the nurse is advised to press hard and write legibly to insure that
the information comes through on the NCR copies.

The Nursing Discharge Summary is highly regarded by accepting facilities as
the most pertinent tool for assisting with maintaining the continuity of care
between facilities. It is important that the most current, and updated
information be provided on this document.




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