Nursing Diagnosis Nanda List

oasis-c script segment 1 [music playing] [male speaker] welcome to the first of a series of training updates to support the use of oasis-c, patient assessment tool for home healthcare patients. this training will present a series of scenarios involving conversations between a nursing supervisor and several clinicians who are seeking guidance on how to best answer several of the oasis-c items. the scenarios will demonstrate completion of several oasis-c items related to patient assessment, the provision of evidence

based care, and discuss the rationale behind the answers. at the completion of this presentation, you should be able to accomplish the objectives shown here. our goal for this training is to assist agencies with accurately reporting patient assessment and the provision of evidence based care, and oasis-c. to meet this goal, we provide examples of how agencies can use the information collected as part of the oasis-c, to obtain the best possible outcomes for home health patients. the first items we will review are mo102 and mo104, which deal with timely care. later, we will cover m1730, depression assessment. m1910, falls risk assessment, m2250, plan of care synopsis, and m2400, treatment

synopsis. karl is a physical therapist who has been scheduled for a start up care visit with mrs. g. mrs. g is an 82 year old woman who was discharged april 5, after a two day hospital stay related to a fall at home. based on the discharge summary, she did not sustain serious injuries from the fall, but does have some bruising. prior to her hospitalization, she was walking without any assisted device. she was sent home with a walker and the referral from her physician includes an order for physical therapy to evaluate balance and coordination, and provide gate training with an assisted device. according to the referral, she was

diagnosed with diabetes six years ago, which is controlled with diet and oral medication. she also has hypertension that is generally well controlled and osteoarthritis. she is widowed and lives alone in an apartment. her daughter, who lives about 15 minutes away, sees her daily. karl made the initial visit to mrs. g on april 6 and when he reviewed the start up care comprehensive assessment, he realized he has several questions about mo102and mo104, dealing with the start up care and the referral date, and also on item m2250, which addresses the plan of care. he discusses his questions with the nurse clinical supervisor, anne, that after noon.

[clinician] i saw mrs. g today for an initial visit. i?d like to talk with you about the patient assessment and see if you have any suggestions before i call dr. hill?s office. i?d like to discuss with you how to handle mo102 and mo104, and also m2250. those are the ones that i?m not sure i?ve been doing right. [supervisor] sure. i know these are items that people still have questions about. thanks. first, let?s tackle mo102 and mo104. i?m looking at the new field we added to the intake form for physician ordered start up care and referral dates,

and it?s a big help to have a place where i know it?s documented, but i still have questions. according to the first form, the first call we got was from the hospital discharge coordinator on april 3, when she had identified that mrs. g would be going home within a few days and would need home care. dr. hill?s office called the same day and said he wanted her seen when she was discharged. then on april 5, the discharge coordinator called with all the referral info and said she was going home that morning, so what do i put for mo102, physician ordered start up care? well, mo102 is the date that homecare services are ordered to begin if the date

was specified by the physician. but it doesn?t sound like dr. hill ever specified a date, correct? no. he just said after hospital discharge. okay, well unless he gives us a specific date, we just check n/a and got to mo104. that?s defined as the most recent date that verbal, written, or electronic authorization to begin homecare was received by the agency. the authorization can come directly from the doctor or on the doc?s behalf, through a hospital or snf discharge planner. that?s where i was unsure. we got a call from the discharge planner on two

different dates, april 3 and april 5, but the item says it?s the most recent date, so i guess that would be april 5? yeah, it sounds like the first call on the third was more like a heads up than a real referral, so you would report the referral date as the 5, when she gave us a firm date and the information we needed for our referral form. let me ask, what would happen if her discharge had been delayed another day or two, so it looked like there was more than 48 hours between the referral and the initial visit, would that make it so we don?t get any credit on the timely care measure? i know we?re supposed to see the patient within 48 hours.

no, that wouldn?t be an issue. let?s review the rules. both the survey tag and the quality measure for timeliness look at whether the patient is seen either on the physician?s specified date, mo102, or within two days of the referral date, mo104, or within two days of the inpatient discharge date, m1005, if the patient is being admitted to home care from an inpatient setting. so, you see the two day rule is influenced by whether the patient is coming to us directly from the community or from an inpatient setting, like a hospital, nursing home, or rehab. say a patient is not coming from an inpatient facility or they were recently discharged from an inpatient facility and we didn?t get any referral

notification until after the discharge. so, they?ve already been home a couple of days. in those cases, the 48 hour clock starts with the date we got the referral. on the other hand, if a patient is in an inpatient facility and we get a referral notification, either prior to or on the date of discharge, then the 48 hour clock starts with the date they were discharged. if there were a delay, like the patient refused the offered visit date and that was going to put us over the limit of the 48 hours after hospital discharge or referral, we?d need to advise the doctor, ask the doctor to approve the delay, and obtain a physician ordered start up care date from mo102. if the delay is caused by a

staffing problem on our end though, that?s not acceptable. research has indicated that patients with more than a 48 hour delay in getting seen do have worse outcomes, so we do our best to make sure that happens. i know it sounds complicated, but it boils down to the fact that we need to either see the patient on the day the doctor told us to see them or within two days of the first opportunity to see them, which would be when we first got the order, the referral date, or when they were discharged from the hospital. if the physician gives a specific date on which he wants the patient seen, that date goes in mo102 and will meet the requirements for timely care, and do well on the

process measure if we visit on that date. if there?s no such date, you mark n/a on mo102 and move on to answer mo104. in mrs. g?s case, the start of the 48 hour clock is the date she was discharged from the hospital and the date of referral isn?t really an issue. okay. i? think i?m set on that. now, let me tell you about my assessment this morning and we can talk about m2250. her pulse, temp, and respirations were within normal limits, but her blood pressure was a little high, 150 over 95. based on our agency perimeters, her blood sugars were reported to be normal while she was in the hospital and she showed me the record of her finger sticks

that she does once a day, which ran between 86 and 150. i did the faces pain scale that?s on our comprehensive assessment and documented that on our pain section. she rated her pain as low right then, but indicated it was moderate to high yesterday. she said she takes tylenol when it gets bad and that helps, but she also says sometimes she puts off doing things because she doesn?t want to get up, due to the pain in her back and knees. her skin looks good, some bruising on her left arm and hip from the fall. her braden score didn?t indicate risk. i checked her feet and they seemed fine. her daughter brings meals, helps her set up medications weekly and assists with household

tasks and showering, but she doesn?t feel safe getting in and out of the tub alone. my assessment showed she has balance and gape problems, as well as low endurance. she likes the walker because she says it makes her feel more stable, but she has trouble rising from the chair and can?t ambulate more than 15 feet without needing to get rest. i didn?t exactly do a formal falls risk assessment. she?s obviously at risk and i couldn?t see the point of putting her through it. oh, and i filled out the med list. other than oral meds for blood pressure and diabetes, she?s only taking a multi vitamin and calcium. oh, and extra strength

tylenol when she needs it. but you should take a look, and we can talk about m2250. okay, i?ll look them over. you know, before we can discuss m2250, which talks about the plan of care based on the comprehensive assessment, i think there are a couple of holes we need to fill in on the assessment. i know. i didn?t get everything in my first visit this morning. she had just arrived home from the hospital and she was exhausted. i was planning on finishing up with her when i see her tomorrow. good. remember you have five days to complete your comprehensive assessment and

can do that in more than on visit. one thing i know i didn?t do is the depression assessment. i would appreciate some pointers on how to broach that topic. i?m no psych nurse. we?re actually in the process of developing a training program on that, based partly on this article by dr. verna carson and katherine vanderhorst, but i can give you the short version here. step one is to develop a rapport with the patient by asking about less sensitive topics first, like physical status. you?ve already done that. then, say something along the lines of that you know she?s dealing with a lot right now and that feeling down or depressed is a

common experience for home health patients. so, you?re going to ask her some questions, which you ask of all your patients, and that will give you an idea of how she?s doing. there are several other depression scales, but we sue the phq-2, which is right in the oasis. so, you read the two questions, just as they?re shown in the assessment form. if the patient scores a three or higher, then we need to follow up. maybe we ask for orders to go back in and do a more thorough screening. or maybe when we report our findings to the doctor, we find out he or she?s already aware and is planning to start some treatment. either way, we won?t be ignoring a problem --

depression -- that has a potential to interfere significantly with a patient?s progress. okay, that helps. i?ll let you know how it goes. anything else? yes. i?d like you to go ahead and do a formal falls risk assessment on mrs. g for a couple of reasons. first, i?m a real believer that it helps us identify not only whether the patient is at risk for falls, but what interventions we should implement. then we can get specific orders for those interventions to put in the physician order plan of care, so everyone on the team can see them. secondly, falls risk assessment is one of those measures that?s going to be

reported publically, starting in the fall of 2010, for all our patients 65 and older. i should let you that we?re going to be implementing a new program for falls risk assessment from the connecticut collaborative for falls prevention, or ccfp. i thought we had to use the missouri alliance tool plus the tug, the timed up and go test? has cms approved a new one? cms doesn?t plan to endorse any specific tool. they say it?s up to each agency to select a tool that?s been validated. that means tested on community dwelling elders and also standardized, meaning it has a standard rating scale. we read

about this ccfp tool. it?s been published in a bunch of peer review journals and the developers have provided documentation, saying they believe it does meet cms?s criteria, so we?re beginning the training next week. for tomorrow though, just do the missouri test plus the tug that?s in our assessment form. okay. i?ll finish up the assessment tomorrow and then we can talk about calling dr. hill and m2250. hey karl, how did it go? oh, it went fine. mrs. g seemed comfortable with the depression questions and probably because i was more comfortable asking them. she scored a two, saying

she felt pretty down for a couple of days after her fall, but has been feeling better since and expressed optimism that she would recover, and be able to resume her previous activities. so since she was less than three, the phq-2 was negative, right? that?s right. i did the formal falls risk assessment two and as expected, it showed that she is at risk due to her age, multiple co-morbids [spelled phonetically], prior history of falls, impermeability, environmental hazards, and pain effecting level of function. it took her over 30 seconds to complete the tug, because she

had trouble getting out of her chair, but she?s not having any incontinence and her vision seems okay with her glasses, which she wears. cognitively, she seems fine, a little forgetful, but not confused or disoriented. okay. let?s take a look at m2250 then. the first row is about patient specific parameters for notifying the physician. we did some education with the docs about this and we asked their preferences. dr. hill said he wants us to use our agency guidelines for vital signs, but he likes to set his own patient specific parameters for blood glucose, when a patient?s diabetic, so you?ll need to find out from him what he wants from mrs. g.

alright, so if he provides patient specific parameters for the blood glucose, i?ll check ?yes? and i?ll be sure to include them on the plan of care. correct. i also have a more general question about this item. if a physician doesn?t identify any patient specific parameters that he wants to use for a patient, but we use our agency standards, can i say ?yes? to this item? no, again, let?s review the rules. if we look here in the manual, you?ll see in section n, it says, ?select n/a if the physician chooses not to identify patient specific parameters and the agency will use standardized guidelines that are

made accessible to all care team members.? the q and a?s that came out in april go into more detail. they explain that if the physician reviews our standardized parameters and agrees that they would meet the needs of the specific patient and then written into the physician ordered plan of care, then we would also be able to answer ?yes?. but ?n/a? is the appropriate response if an agency uses their own agency standardized guidelines and the physician has not agreed to include them in the plan of care for this particular patient. ?no? is the correct response if there are no patient specific parameters on the plan of care and the agency will not use their own standardized physician notification parameters for

this patient. okay. that makes sense. now, rule b is diabetic foot care, including monitoring and education. so again, since she?s diabetic, i need orders for both of these to be able to say ?yes? to this item. right. okay, rule c is falls prevention interventions. since we got orders at the time of referral to evaluate balance and coordination and provide gate training with an assisted device, can i just say ?yes? to this one? let?s look at the manual again for 2250, section n. it says, ?the patient

condition has to be discussed and there has to be an agreement as to the planned care between the home health agency staff and the physician. the way we understand it, in the rare case that a physician referral for services is received by the agency, and it completely addresses all the patient?s needs identified during your assessment, it would be appropriate for you to incorporate those orders into the plan of care and you could select ?yes? for the item in 2250. if, as is more likely the case, the referral orders don?t completely address patient needs or don?t completely specify the needed interventions, and a conversation with the doctor would be necessary to

establish agreement on the plan of care. for example, it sounds like this patient needs a lot of other things besides gate training to address her falls risk. yes, i plan to discuss the need for strengthening exercises for balance, coordination, and endurance. i think she?ll be able to transition to a cane over the next few weeks. she also needs some teaching on environmental issues and home safety, proper footwear, etcetera. you know, for stuff like home safety, i don?t know why we need a doctor?s order. those are things we?ve always done anyway. am i now not supposed to do anything like monitoring or education,

unless we have an order? well, it?s true that some of the best practices captured in m2250 include care that we might have routinely provided to a patient without a specific order in the past. for instance, if you?re visiting a patient for the first time and you notice an environmental problem that could be a falls risk, you would try to address the issue through intervention or education. you wouldn?t wait to get a physician?s order, but we?ve seen that when we have orders and the physician ordered plan of care, it?s a reminder to all clinicians who see the patient, there?s more accountability and patients are getting more consistent care, plus

we want to get credit for performing these best practices, like falls or pressure ulcer intervention, and to mark ?yes? on m2250, you have to have an order in that plan of care. okay. thanks for the explanation. i?m all for getting credit. here?s something i get confused about though. if i didn?t do an actual falls risk assessment, i?d just assume she was at risk, discussed it with the doctor, and got orders for falls risk interventions. could i still say ?yes? on m2250? you?re right. it?s one of those things that people seem to be getting hung up on. this item is not about documenting whether you did an assessment, like her

falls assessment. you?ve already documented that in m1910. it?s asking about what you?ve discussed with the physician and what orders are in the plan of care. here, let?s look at this flow diagram from the april 2010 q and as. you can see if you did the assessment, formal or informal and it was positive, of if you did do an assessment, your choices are the same, yes or no, depending on whether there are any orders in the physician ordered plan of care related to this item. but if you did an assessment and it was negative, then you can say the intervention is ?n/a?, not applicable. the only way an assessment figures into this item, is that you just can?t say ?n/a?, not applicable, if you haven?t

done an assessment, because you wouldn?t have any way to really be sure whether the patient had symptoms or was at risk, so if you don?t do a falls risk assessment, for example, you can never mark ?n/a?, patient is not as risk for falls. yes and no are your only choices. okay. got it. for road d, the depression assessment, i?m marking n/a, because i did an assessment and it was negative. if she had a diagnosis of depression, but her phq-2 was negative right now, could i still put n/a? no. the oasis-c guidance manual indicates that n/a is only an appropriate response to m2250d, if the patient has a negative result on screening and has no

diagnosis of depression. for the next row on pain, i definitely want to talk with dr. hill about this. i?m not sure she really has adequate pain control and i?m not going to be able to have her meet her rehab goals if she?s in too much pain from her knees and back to get up. some of her discomfort does seem related to her fall and she says she?s feeling better every day. i guess my plan would be to see what dr. hill thinks and get orders for pain to be assessed during every visit, evaluate how well her meds are working, and maybe provide instruction on alternative methods of pain relief. one thing i?m not sure about is how detailed those

orders have to be. do they have to say the intervention, just like it?s stated in m2250? no. it needs to be a specific order for an intervention. there was a q and a about that recently. if the order read ?monitor and mitigate pain,? that wouldn?t be enough. in order for a specific intervention, such as medication or massage, would need to be included. okay. now, the last two rules in m2250 are on pressure ulcers, but you said she was negative on the braden, right?

yes. so, i can just put n/a, right? right. so, that?s it for a 2250. are you ready to call dr. hill? i don?t suppose i can just fax over my findings and plan interventions and assume he?s in agreement? nope. cms guidance is clear that there has to be two way communication with the doctor about the patient?s condition, based on your assessment, and it has to be in agreement as to the plan of care between the agency clinician and the doctor. it can be via phone, voicemail, fax, or other means, as long as it appropriately conveys the message of the patient?s status and the physician then responds.

actually, about half of our physicians have said they do prefer to be contacted by fax, when we offered them that option. we have developed the sbar form, where we document our findings during the assessment, indicate our recommendations for interventions, and ask them to indicate any other orders or other interventions they would like added. physicians appreciate the concise and uniform approach to reporting on their patients that is used in the sbar format. most of them do return the signed form within the required time window. i think it helps that in addition to educating the doctors, we?ve also tried to develop good relationships with their office

staff. anyway, dr. hill prefers to be called. you can leave a voicemail or a message with his staff, if you can?t reach him directly. even on a call, it helps to use the sbar format because it provides a brief statement of the problem, clinical background information pertinent to the situation, findings from your assessment, and your recommendations or questions. it saves time for you and the physician. okay, one last question. it?s about timing. mrs. g?s start up care date was the 6. today?s the 7 and i?ll do a call to dr. hill?s office this afternoon. what do i do if i don?t hear back from him by the close of the startup care window,

which would be the 10? how do i respond to the m2250 items? for the pressure ulcer items, i can still say n/a, because they?re not relevant for this patient, but for the other items, can i just respond ?yes?, since i?m pretty sure he?ll eventually write orders for those interventions? orders we get after the mo090 date, the day oasis was completed, don?t count for this item. the orders can be verbal or written, but if you complete the oasis and we don?t have those orders, you can?t say yes. you could delay completing the assessment for another day, but we?ve talked about this as an agency and we want to continue to get our assessments in during the time window. cms has said

they don?t expect a hundred percent on these measures and you?ve done your best. the important thing is that we address the patient?s needs. okay. i?m going to just try to remember these four things. first, that the plan of care item, m2250, is about what orders are put in the physician ordered plan of care, verbal or written, at the end of the five day soc window. right, or the two day roc window. and second, if we get orders, then i can mark ?yes?, but i can only mark ?not applicable? if i?ve done an evaluation that indicates the patient is not at risk or that the best practice is not applicable for the patient.

right. and third, you need to document that there has been two way communication between you and the physician about your findings. oh, and fourth -- to look at the manual when i get to m2250, because there?s a lot of stuff in there that it doesn?t say in the actual item. that?s true for a lot of these new items. in the beginning you just have to keep going back to the manual and the q and a?s until you?ve got it down. karl, the physical therapist, just gave a pretty good review of some of the major takeaway points for this scenario, which focused on several of the more challenging oasis-c items completed at startup care. but let?s go over them once

again, starting with timely care. mo102 is the date that homecare services are ordered to begin. if the date was specified by the physician. if there is no such date, mark ?n/a? on mo102 and move on to answer mo104. mo104 is defined as the most recent date that verbal, written, or electronic authorization to begin homecare was received by the home health agency. the authorization can come directly from the doctor or on the doctor?s behalf, through a discharge planner. both the survey tag and the quality measure for timeliness look at whether the patient is seen either on the physician?s specified date or within two days of the referral date, or within

two days of the inpatient discharge date, if the patient is being admitted to homecare from an inpatient setting. next, the supervisor provided karl with some tips on approaching the phq-2 depression screening, to help and identifying a problem -- depression -- that has a potential to interfere significantly with a patient?s progress. step one is to develop a rapport with the patient by asking about less sensitive topics first, like physical status. step two is to acknowledge that feeling down or depressed is a common experience for home health patients and inform the patient that you?re going to ask some questions that you ask all your patients. step

three is to read the two questions just as they are shown in the phq-2 on the oasis-c assessment form. if the patient scores a three or higher then follow-up is needed. these tips were taken from an article by dr. verna carson and katherine vanderhorst, which appeared in the march, 2010 edition of the journal home healthcare nurse. our scenario went on to explore the why and how of conducting a falls risk assessment that meets the criteria for m1910. here, the supervisor explained that conducting the assessment, using a formal multi factor falls risk assessment tool, not only provides a standardized approach to determining

whether a patient is at risk for falls, but helps to identify what interventions are needed. it?s up to each agency to select a tool that?s been validated, meaning it?s been scientifically tested on community dwelling elders, and also standardized, meaning it has a standard rating scale. like many agencies, this one has been using an assessment that incorporates the timed up and go, or tug, test as one of the components in a multi factor assessment that also examines age, home morbid conditions, history of falls, medications, impaired mobility, environmental hazards, and pain affecting level of functioning. they?re in the process of looking into different falls risk tools that they believe may better

meet their agency?s needs and also meet the cms criteria for m1910. note that when the oasis-c guidance manual states that a screening or assessment tool must be validated through scientific testing, this can be interpreted to mean that the predictive ability of the tool to identify patients with a need for further follow-up or intervention for the health problem of concern -- that is depression, falls, pressure ulcers, pain -- has been the subject of one or more research studies who?s subjects reflect the home health community dwelling elder population and the study, or studies, have been subjected to a peer review process, which found that the study rigor, such as design, sampling, sample

size, statistics, and the results, such as external validity and generalized ability, were adequate and are associated with desired outcomes. our scenario went on to look at the components of m2250, the plan of care synopsis, including the use of the m2250 flow diagram to determine when no, yes, or n/a is the appropriate response. the flow diagram can be found at the address shown here. the discussion also included a review of guidance on m2250 that can be found in section n of the oasis-c guidance manual, available for download from the cms website at this address. lastly, we stressed the importance of two way communication with the doctor about the patient condition based on the

conditions assessment, including the need for an agreement on the plan of care between the agency clinician and the doctor during the five day startup care or two day resumption of care window. use of the sbar format, reviewing situation, background, assessment, and recommendation can promote a concise and uniform approach to reporting, which also saves time for you and the physician. [end of transcript] cms: oasis-c script segment 1 2 10/25/10 prepared by national capitol captioning 200 n. glebe rd. #710 (703) 243-9696 arlington, va 22203