Questions for an acute care nurse.

caseyuptonurse · Mar 26, 2016

Are you glad that you got that all out? I don't think that has anything to do with being an "LTC" nurse... I feel those are basic report questions. Besides asking about the admitting diagnosis two days later...

But anyways why are you so upset that a nurse wants a fully detailed report on their new patient? I work in subacute and sometimes when patients come through those doors I get NO REPORT and I get discharge instructions that are meant for the patient that just tell me the patient should eat healthier or drink more water... Nothing that is important to me as the nurse.

Unlike in your hospital system or whichever setting you work, we don't have the same computer access where we can pull up all of a person's records.

Keep that in mind and be mindful when you give report. I don't see anything wrong with what is being asked of you with those questions.

IsabelK · Mar 26, 2016

I'm an NP in LTC, so I'm going to give you the prescriber perspective.

Faxing the discharge papers and med list by 1 PM if pick-up is going to get the patient to the LTC site later than that is must. We don't have an on-site pharmacy. Our pharmacy has to receive the orders by a certain time to get them on the early run (usually arrival around 5 pm). If they don't, the meds might come on the late evening run, but they may not. If the meds don't come on the late run, they won't come for another 24 hours and that's a delay in care and can be extremely dangerous for the patient especially in cases of dig, Coumadin, antibiotics, antipsychotics, etc. The facility has limited emergency supply and each patient (resident) has to have his or her own supply of meds unless it's a stock med like Tylenol. If I can't get a discharge med list in time, the facility can also get deficiencies from the Department of Health for a delay in care. The other issue with waiting for a med list is that each order has to be entered onto the MAR and a lot of LTCs are still hand-writing so I have to write the orders and then an LPN or RN has to transcribe them correctly onto the MAR (and we still handwrite) and then there has to be a second check. This all usually has to happen by the 5 PM med pass. And the orders have to be faxed to pharmacy but only after both checks are done. It's a cumbersome but necessary process. If one of these steps doesn't happen I have a significant delay in care.

The facility needs the admission diagnosis for billing and for the reason for admission. The admission has to be appropriate. If it's not clearly stated (and sometimes you'll be getting calls from billing, not admissions or the nurses) there needs to be clarification. In those cases, just refer the caller to medical records and the caller can ask for the admission H&P again. When I do my notes I clearly state the reason for admission, but the billing folks don't see my notes.

All LTC facilities have to have clearly stated orders about start and stop dates on antibiotics. I have to write, for example, "Keflex 500 mg PO 2x daily x7 days for left lower extremity cellulitis". If there is no stop date, I have to clearly state that as in "Macrodantin 100 mg PO daily for UTI prophylaxis--NO STOP DATE". This is a requirement from CMS and from the Department of Health. It's a deficiency if this isn't done. The MAR also has to reflect that the provider addressed the stop date. The pharmacy also needs to know there is no stop date so the pharmacist on the other end of the fax machine doesn't call for clarification and so that the pharmacy consultant who comes in and audits charts doesn't start saying, "This is not what the order should look like". It also saves a lot of calls from the nurses on the units asking for order clarification. So if there is no stop date and there is not a clearly stated reason for no stop date, you will get a call asking for clarification before the order is taken off the order sets at the LTC.

LTC sites need detailed wound information because they get deficiencies and lose money based on wounds if there is no documentation that the patient came in with a wound. They also need detailed information about the wound prior to admission so the appropriate dressings, topicals, etc can be ordered. Again, if it's not a stock item, it has to be ordered separately from pharmacy or from the facility's medical equipment supplier and we need to know as soon as possible what those are. For example, I have a resident with a lot of complex stasis ulcers and diabetic ulcers. We needed specialty supplies for him when he was being discharged back to the facility that we didn't have. I needed those details to get the supplies in time for him to come back.

Hope that helps...

mtjoanna · Mar 26, 2016

I've been a noc nurse at a LTC for 3 years now. I won't rehash all of the (very accurate) details given by IsabelK above, but will add a couple other things that I have noticed during my time there. The information that is sent to the admission committee is often not at all passed on to the nurses working the floor. You may send a fax with all pertinent information, but what the floor nurse gets is: admit for room 302 arriving after noon today. 93, diabetic. Has some sores." We have actually had to wait almost 24 hours for admission orders to arrive, and often it is simply the most recent med list with some crossed off and others check-marked. We receive only the discharge paperwork that the patient is typically sent home with, and while none of us should ever stop learning, I need more than a d/c diabetic education form to go off of. So yes, I have called to ask the previous place about my new resident when their needs are complex and the info that I have received is not accurate or complete. Not trying to make the life of the other nurse difficult, just trying to be able to provide some decent care.

dudette10, MSN, RN · Mar 26, 2016

Are you glad that you got that all out? I don't think that has anything to do with being an "LTC" nurse... I feel those are basic report questions. Besides asking about the admitting diagnosis two days later...
But anyways why are you so upset that a nurse wants a fully detailed report on their new patient? I work in subacute and sometimes when patients come through those doors I get NO REPORT and I get discharge instructions that are meant for the patient that just tell me the patient should eat healthier or drink more water... Nothing that is important to me as the nurse.
Unlike in your hospital system or whichever setting you work, we don't have the same computer access where we can pull up all of a person's records.
Keep that in mind and be mindful when you give report. I don't see anything wrong with what is being asked of you with those questions.

I'm not upset. I'm trying to understand why I get asked certain questions. If you don't want to answer, don't answer, but don't assume I have negative views. I'm trying to understand reasoning.

Nurse to nurse in the acute care setting, we don't go over wounds in explicit detail because they are all documented already, including wound care. We don't give end dates for abx because they aren't known or change when the culture comes in. Discharge papers have orders, and unless there is an order I didn't get to during my shift, we don't go over every order.

dudette10, MSN, RN · Mar 26, 2016

I'm an NP in LTC, so I'm going to give you the prescriber perspective.
Faxing the discharge papers and med list by 1 PM if pick-up is going to get the patient to the LTC site later than that is must. We don't have an on-site pharmacy. Our pharmacy has to receive the orders by a certain time to get them on the early run (usually arrival around 5 pm). If they don't, the meds might come on the late evening run, but they may not. If the meds don't come on the late run, they won't come for another 24 hours and that's a delay in care and can be extremely dangerous for the patient especially in cases of dig, Coumadin, antibiotics, antipsychotics, etc. The facility has limited emergency supply and each patient (resident) has to have his or her own supply of meds unless it's a stock med like Tylenol. If I can't get a discharge med list in time, the facility can also get deficiencies from the Department of Health for a delay in care. The other issue with waiting for a med list is that each order has to be entered onto the MAR and a lot of LTCs are still hand-writing so I have to write the orders and then an LPN or RN has to transcribe them correctly onto the MAR (and we still handwrite) and then there has to be a second check. This all usually has to happen by the 5 PM med pass. And the orders have to be faxed to pharmacy but only after both checks are done. It's a cumbersome but necessary process. If one of these steps doesn't happen I have a significant delay in care.
The facility needs the admission diagnosis for billing and for the reason for admission. The admission has to be appropriate. If it's not clearly stated (and sometimes you'll be getting calls from billing, not admissions or the nurses) there needs to be clarification. In those cases, just refer the caller to medical records and the caller can ask for the admission H&P again. When I do my notes I clearly state the reason for admission, but the billing folks don't see my notes.
All LTC facilities have to have clearly stated orders about start and stop dates on antibiotics. I have to write, for example, "Keflex 500 mg PO 2x daily x7 days for left lower extremity cellulitis". If there is no stop date, I have to clearly state that as in "Macrodantin 100 mg PO daily for UTI prophylaxis--NO STOP DATE". This is a requirement from CMS and from the Department of Health. It's a deficiency if this isn't done. The MAR also has to reflect that the provider addressed the stop date. The pharmacy also needs to know there is no stop date so the pharmacist on the other end of the fax machine doesn't call for clarification and so that the pharmacy consultant who comes in and audits charts doesn't start saying, "This is not what the order should look like". It also saves a lot of calls from the nurses on the units asking for order clarification. So if there is no stop date and there is not a clearly stated reason for no stop date, you will get a call asking for clarification before the order is taken off the order sets at the LTC.
LTC sites need detailed wound information because they get deficiencies and lose money based on wounds if there is no documentation that the patient came in with a wound. They also need detailed information about the wound prior to admission so the appropriate dressings, topicals, etc can be ordered. Again, if it's not a stock item, it has to be ordered separately from pharmacy or from the facility's medical equipment supplier and we need to know as soon as possible what those are. For example, I have a resident with a lot of complex stasis ulcers and diabetic ulcers. We needed specialty supplies for him when he was being discharged back to the facility that we didn't have. I needed those details to get the supplies in time for him to come back.
Hope that helps...

Thank you! That does help.

In acute care, I try to get the meds "caught up" through the evening doses if appropriate, and I verbally report the meds due at bedtime. I figured it had something to do with no on-site pharmacy, but I wasn't sure. Sounds like the same goes for wound care. I try to change all dressings prior to transport back.

Would sending the final ID note if no end date to the abx be helpful for documentation purposes?

dudette10, MSN, RN · Mar 26, 2016

I've been a noc nurse at a LTC for 3 years now. I won't rehash all of the (very accurate) details given by IsabelK above, but will add a couple other things that I have noticed during my time there. The information that is sent to the admission committee is often not at all passed on to the nurses working the floor. You may send a fax with all pertinent information, but what the floor nurse gets is: admit for room 302 arriving after noon today. 93, diabetic. Has some sores." We have actually had to wait almost 24 hours for admission orders to arrive, and often it is simply the most recent med list with some crossed off and others check-marked. We receive only the discharge paperwork that the patient is typically sent home with, and while none of us should ever stop learning, I need more than a d/c diabetic education form to go off of. So yes, I have called to ask the previous place about my new resident when their needs are complex and the info that I have received is not accurate or complete. Not trying to make the life of the other nurse difficult, just trying to be able to provide some decent care.

That sounds like an internal process issue. Why doesn't the person I talk to provide you the information I tell them? The packet our unit secretary prints off has a lot of other stuff in it besides the discharge sheets. Do you--the bedside nurse--never see it?

mtjoanna · Mar 26, 2016

That sounds like an internal process issue. Why doesn't the person I talk to provide you the information I tell them? The packet our unit secretary prints off has a lot of other stuff in it besides the discharge sheets. Do you--the bedside nurse--never see it?

Pretty much not. I don't know how it is in the new place that I'm starting on Monday but in the facility I just left, for admissions we would sometimes get hundreds of pieces of paper, often triplicate information that we had to sort through or nothing at all. Either feast or famine, both of which have their challenges. Of course, at night, I didn't have access to the admin folks who had the paperwork, so making sense of what I had (or didn't) was up to me, which sometimes did end up with a phone call trying to get some basic--or detailed--info.

For residents that we sent to the hospital and received back (after a bout of pneumonia, bowel impaction, heart attack, etc) we only receive the typical discharge paperwork you send home with a patient--we don't get the nurse notes, doctor notes, diagnosis information or anything. We have to specifically call and ask those questions; the relationship between this facility and the local hospital is not a good one--they don't seem to feel that we are "real" nurses doing important "nursey" things and we feel that they give our residents substandard care, which makes for a lot of distrust and friction when trying to coordinate care. Another of the reasons I left the place.

dudette10, MSN, RN · Mar 26, 2016

Mtjoanna: I usually give the same report that I would give to another acute care nurse if the patient was staying with us. But that doesn't help you at all if I'm not talking to the person who will actually be rendering care and who doesn't pass pertinent info off. Must be very frustrating!

IsabelK · Mar 26, 2016

Yes! All consult notes are helpful, especially for me. It helps me do a medical plan of care for the patient/resident and it helps the nurses know what to expect. If you can send that information, it would be appreciated on the LTC end. We really just want good continuity of care for the patient.

mtjoanna · Mar 26, 2016

Mtjoanna: I usually give the same report that I would give to another acute care nurse if the patient was staying with us. But that doesn't help you at all if I'm not talking to the person who will actually be rendering care and who doesn't pass pertinent info off. Must be very frustrating!

Indeed it is! When you send a resident to the hospital with vomiting, a bloated, taut abdomen and NO bowel sounds whatsoever and you get yelled at by the DON (with a few expletives thrown in for effect) because of the "unnecessary" additional paperwork for her, the resident stays at the hospital for 5 days and then returns without any nurse notes, doctor notes or any idea of what her treatments were, it's hard to defend yourself to the DON. And it makes one question one's own assessment skills, though the very fact that she was there for 5 days tells me that something was wrong, but not what, and not what complications I should watch for.

dudette10, MSN, RN · Mar 26, 2016

Yes! All consult notes are helpful, especially for me. It helps me do a medical plan of care for the patient/resident and it helps the nurses know what to expect. If you can send that information, it would be appreciated on the LTC end. We really just want good continuity of care for the patient.

And so do I! Next time, I'll take a look at the content of the packet of info we send. I think the unit secretaries have an automated field that they click in Epic when a patient is transferred to an LTC to print out info, but I don't know what info is grabbed and printed when that happens. I do know the packet is quite thick, as mtjoanna alluded to, but it may be cumbersome for an LTC bedside nurse to sift through. I'm not sure if there is an alternative, though...