Physical Therapist looking for nursing perspective on care plans, patient hand off etc

[PTvisitor]

Hello-

I am the lead inpatient PT at a small CAH. Our patients are primarily med/surg and swing bed patients. I have been looking online for resources regarding interdisciplinary care planning, best practices for hand off communication between disciplines etc. This forum seems to be very active with lively discussion :) so I'm hoping for some ideas and recommendations that have worked for others.

Our facility uses an EMAR with PT/OT documenting electronically as well as adding to the nursing care plan electronically. Many of the nurses prefer using the kardex and therapies typically write the care plan there as well. Additionally, we update the white boards in patient rooms with the pt's current level of mobility, need for assist, recommendations for ceiling lift etc.

Each discipline's daily documentation has a section that carries over to the nursing multidisciplinary summary for ease of access to the nurses, physicians and other providers. If there is some extremely critical information that I feel the nurses should be aware of I have the option of documenting that in the nursing assessment section so it will definitely be seen by the RN.

In general, therapies at our facility have a good relationship with the RNs, CNAs, physicians and other providers so there is a lot of face to face communication individually as well as a daily team meeting with all disciplines represented.

I feel very blessed to be working in a facility with such good communication because I know it is quite rare.

However, I feel that some of the documentation tends to be redundant and I would like to pare it down a bit. It is quite time consuming and difficult to make sure all of the places I document are saying the same thing at the end of each day :)

Would you mind sharing how this is handled at your facility? Some of my specific questions are:

1) Do the therapists document on the kardex themselves or do the nurses update based on the care plan? Or on face to face reports?

2) Do you have access to the therapy notes and ,if so, what information do you find helpful to you?

3) How detailed are the portions of the care plans initiated by therapy? Or do the therapist even enter items on the nursing careplan??

4)Anything else that you've found to be helpful as you collaborate with therapies?

Thank you!!

[Corey Narry, MSN, RN, NP]

Hi and welcome to AN! It's always good to have non-nurses who are part of the healthcare team join in here.

I work at a large academic medical center (affiliated with a health sciences campus so we get students of all types from the schools of medicine, pharmacy, nursing, and PT).

We use Epic for our electronic health record. In the past, PT, OT, and SLP notes were hard to find because they were in the Kardex section of the EHR. While nurses were probably familiar with how to look them up, providers like myself (NP, residents, attendings) had a hard time figuring out what the patient had done during rehab sessions.

Now all rehab service professionals write a progress note that appears in the "Notes" section of the EHR. It is the same section where daily progress notes from providers are found. We found that it worked best for fostering interdisciplinary communication. I work in a high acuity ICU with dedicated PT, OT, and SLP and we are big on early mobilization.

[PTvisitor]

Thank you for your reply. Our facility has been considering a transition to EPIC and I did like the ease of transfer of information from the ancillary notes to the nursing side.

It is my impression that the nursing care plan on the electronic record would be the "legal" document and that the paper kardex would be more of an informal tool used by the nursing staff for hand off communication and guiding care throughout the stay. Do the nurses typically create the kardex from the electronic care plan along with their own assessments, observations and such? I am not really familiar with this part of nursing practice so don't want to make a suggestion to our RNs that is completely off base.

Is it common practice for the nurse to review the notes of the other team members daily (on med surg)? I wouldn't imagine the RN could read every note entirely at each shift but a summary of each discipline? Or just when there is an issue or concern to be clarified?

I have done my share of educating physicians as to how to access my notes so I can feel your pain there :) We spend soooo much time documenting it is a shame no one reads our notes lol

I am fortunate to have such close communication with all the team members on a daily basis. Being at a small facility has a big advantage that way. Fewer chances for things to slip through the cracks when everyone has the mind set that "the buck stops here" with safety, discharge planning, etc.

Also, I am very new here but want to extend my condolences to all of you that have been grieving over the events of the last week. This community is obviously a blessing to many and I pray for comfort for family, friends and this community.