kardex

[afteralltheseyears]

I am a new DON in a critical access hospital that has 20 extended swing patients (nursing home type patients) who reside here. My specialty is ER and I have no experience with LTC so am looking for advice from you experts.

A longstanding problem at this facility has been getting the nurses to keep their care plans for the extended swing patients up-to-date...... and obviously they are not using them to plan and deliver care. I think one step toward changing the culture to one in which they use care plans in their daily work (and base their documentation on them) is to give their shift reports utilizing the resident's problem list. We don't have electronic records yet so I wonder about devising a kardex that includes the patient's problem list which is used to communicate and give report with? Any one do that in your ltc facility? If anyone has such a kardex could I see what yours looks like?

Any other suggestions for getting staff to plan and deliver care based on care plans? Would it be beneficial to buy the premade care plans on a disc that staff could individualize to the patient, print out and put on the chart?

thank you

Afteralltheseyears

[CoffeeRTC, BSN, RN]

Just wondering...what is the average length of stay?

I dunno...I was an assessment co-ordinator and all I did was care plans. Yes...they do serve the purpose of planning care, but I will admit to the fact that I haven't looked at a care plan since and still provide great care.

Most of the residents that I have are now averaging about 2 months or less legnth of stay and the other wing is more LTC. How do I plan care..report first off, then knowing the dx list, reviewing MAR and TARs. The care plans that we have are pages and pages of written word to satisfy the state.

When you get a good report..this makes things easy...if not, I will skim thru the charts on the newer residents and look over our writtne report.

Getting pack to your issue...a Kardex is great and with only 20 pts, updating care plans and the kardex should be do able. A documentation inservice sounds needed. Who is doing your MDS?

As far as forms..Briggs used to have a ton of kardex like forms and careplans.

[afteralltheseyears]

We are the only hospital in our state that has been given the designation of CAH with extended swing patients who permanently reside here (in other words-we have 20 nursing home patients in our hospital who are permanent residents). We don't have to do MDS's on them as we are not considered a nursing home. The other 4 beds are reserved for our occasional observation/inpatient admission or skilled swing patient. We also have a 2 bed ER.

I agree that often it feels like much of the paperwork we do is simply to please the state but since we have to do it lets do it in a way that will make it more likely it is kept up and done well....and I think the best way to do that is incorporate it in our care. Is anyone able to pull that off at their facility?

I'll check with Briggs to see if they have a kardex like I'm thinking of. Thank you

[CompleteUnknown]

I think I can see what you're trying to achieve and it sounds like you're on the right track and yes, it's doable. I agree with you that most people want to do the right thing so perhaps it would be a good idea to talk to everyone and find out why it's not getting done now. Could be they don't really know how, could be a lack of time, could be they don't really see the point, could be just that it's just been allowed to slide.

The thing about care plans for nursing home patients is that with only 20 patients and a small staff, everyone probably knows the patients really well and knows how to care for them without needing to look at the care plan all that often. In this situation you probably need to make sure the care plans reflect what is actually being done rather than needing to have the care plans there to 'guide care'. Heresy I know, but in my experience that's how it is in small facilities. The expections would be things like if the care plan states 2 staff assist but this isn't happening and even then it's more of an issue with the staff not doing what they know they should rather than the staff not thinking to use the care plan to guide them, if you know what I mean.

There are pluses and minuses to using a kardex type system if it's written in pencil. Good thing is that it's written in pencil and can be gone forever. Bad thing is that it's written in pencil and can be gone forever lol. With a diary or similar system, staff can look back for a brief look at what's happened since they were last on duty and you have it in writing that such and such happened on such and such day if needing to track why something wasn't documented or followed up. This can come back to bite you too so it's a bit of a judgement call and a good idea to keep diaries and the like away from surveyors.

Just some thoughts, you probably don't need them, it sounds like you're going to do fine. :)

[nursel56]

The kardex system we used way back when was simple, flexible and accessable to all. Before care plans were co-opted into the NANDA system, as I recall - it was a collaborative effort with all members of the team providing input, or updating a change in condition or new order quickly. There was a section for "nursing goals" with a time period.. They just used standard medical terminology.

They were written in pencil and kept within sight and reach at the nurse's station. I loved that system! I always had an "if it aint broke don't fix it" philosophy. I know many people disagree- but I thought I'd throw in my 0.02 as someone who remembers the old ways of doing things.

[Nurse Mentor Nancy, MSN, RN, NP]

I have 11 years experience as the day Nurse Manager/ADON, MDS coordinator and Fall Risk Coordinator in a 35 bed SNF that is part of a CCRC (Continuing Care Retirement Community).

Your idea of visiting other facilities is a good one. I would suggest you also call facilities that most resemble yours. I have found that every facility's care plan writing process is different, but we all have the same problem. The nurses do not write, and/or do not read and/or do not follow the nursing care plans.

I do the long term care plans for each resident on admission using the RAP categories from the MDS and using language from the RAP triggers. You could do the same thing with your admission care plans without having done a MDS.

Then every quarter I update the long term care plan after completing the MDS. The day charge RNs or floor LPNs go to the care plan meetings that occur soon after the MDS is finished, review my changes and update the care plan as needed.

I am proud to say that we have never been sited on our surveys for any problems with our care plans. In fact, we have been complemented by survey teams because the plans are so resident centered. I do not use canned care plans. I omit the obvious, like "Give medications" or "Leave the call bell in the resident's hand when you leave the room" What nurse would not give medications. We also have standards that all nursing staff are oriented to (like leaving the call bell in their hand) so I only care plan when there is an exception to that standard. Instead, I develop interventions specific to each resident. I have a library that I developed to choose from so that my care plans do not take forever to write. Also, I listen to report and read the 24 hr reports every day so I am very familiar with our residents.

I also like the idea of kardexes. I introduced this using short term problems like wounds, infections, falls and pain. The nurses were supposed to review during report and make changes then and again before their shift ended. Because not all the nurses on every shift updated the kardex, my idea failed. Instead, my staff use different sheets for each part of the unit to pass information on to the nurse the next day.

We have all our nurses and most of our CNAs sit in report for all three shifts. I find the advantages outweigh any disadvantages: increased team work, time to discuss issues and what is expected during that shift.

I have taught my day LPNs and RNs how to write care plans in CNA friendly language. We have also talked about what needs to go into the verbal taped report at the end of the shift and what does not. We have yet to do much inservicing on how to document. We have policies on documenting for Medicare A residents, incidents and psychotropic drugs, etc that are not always followed. I continue to work on holding staff accountable for that.

Hope this helps. I am always looking for topics to write articles about online. I think I will use your questions for my next article. Thanks and good luck.

[CompleteUnknown]

I have 11 years experience as the day Nurse Manager/ADON, MDS coordinator and Fall Risk Coordinator in a 35 bed SNF that is part of a CCRC (Continuing Care Retirement Community).

Your idea of visiting other facilities is a good one. I would suggest you also call facilities that most resemble yours. I have found that every facility's care plan writing process is different, but we all have the same problem. The nurses do not write, and/or do not read and/or do not follow the nursing care plans.

I do the long term care plans for each resident on admission using the RAP categories from the MDS and using language from the RAP triggers. You could do the same thing with your admission care plans without having done a MDS.

Then every quarter I update the long term care plan after completing the MDS. The day charge RNs or floor LPNs go to the care plan meetings that occur soon after the MDS is finished, review my changes and update the care plan as needed.

I am proud to say that we have never been sited on our surveys for any problems with our care plans. In fact, we have been complemented by survey teams because the plans are so resident centered. I do not use canned care plans. I omit the obvious, like "Give medications" or "Leave the call bell in the resident's hand when you leave the room" What nurse would not give medications. We also have standards that all nursing staff are oriented to (like leaving the call bell in their hand) so I only care plan when there is an exception to that standard. Instead, I develop interventions specific to each resident. I have a library that I developed to choose from so that my care plans do not take forever to write. Also, I listen to report and read the 24 hr reports every day so I am very familiar with our residents.

I also like the idea of kardexes. I introduced this using short term problems like wounds, infections, falls and pain. The nurses were supposed to review during report and make changes then and again before their shift ended. Because not all the nurses on every shift updated the kardex, my idea failed. Instead, my staff use different sheets for each part of the unit to pass information on to the nurse the next day.

We have all our nurses and most of our CNAs sit in report for all three shifts. I find the advantages outweigh any disadvantages: increased team work, time to discuss issues and what is expected during that shift.

I have taught my day LPNs and RNs how to write care plans in CNA friendly language. We have also talked about what needs to go into the verbal taped report at the end of the shift and what does not. We have yet to do much inservicing on how to document. We have policies on documenting for Medicare A residents, incidents and psychotropic drugs, etc that are not always followed. I continue to work on holding staff accountable for that.

Hope this helps. I am always looking for topics to write articles about online. I think I will use your questions for my next article. Thanks and good luck.

Great post, I love the bit I've bolded, care plans shouldn't be used (in my opinion) for things that are just common sense or are part of the job description anyway. If only everyone had as much common sense as you!

[Nurse Mentor Nancy, MSN, RN, NP]

Right on, Complete! Let's cut down on any unnecessary paper work or tasks that take away from what is really important. Let's do what we do best: Intervene to solve our patients' nursing problems, prevent illness and complications and save lives!