Continuity of Care in Inpatient Nursing

In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of continuity of care in order to:

• Provide and receive report on assigned clients (e.g., standardized hand off communication)
• Use documents to record and communicate client information (e.g., medical record, referral/ transfer form)
• Use approved abbreviations and standard terminology when documenting care
• Perform procedures necessary to safely admit, transfer or discharge a client
• Follow up on unresolved issues regarding client care (e.g., laboratory results, client requests)

Simply defined, the continuity of care is defined as the sound, timely, smooth, unfragmented and seamless transition of a client from one area within the same healthcare facility, from one level of care to a higher and more intense level of care or to a less intense level of care based on the client's status and level of acuity, from one healthcare facility to another healthcare facility and also any discharges to the home in the client's community.

Maintaining the continuity of care requires that the nurse, and other members of the healthcare team, identify current client needs and then move the client to the appropriate clinical area, to the appropriate level of care, and to the appropriate healthcare facility in a timely and effective manner.

Communication, collaboration and cooperation among and between appropriate healthcare team members and the client are essential components of the continuity of care.

Providing and Receiving Report on Assigned Clients

Reports at the end of a shift insure a seamless, unfragmented transition from one shift of nursing staff to the next. These "Hand off", or change of shift, reports are a critical component of nursing care.

These reports must minimally include:

• The patient's name, their doctor's name, the date of admission and diagnosis
• All unresolved issues and uncompleted tasks
• Priorities of care
• Significant data and information about the patient's status and condition
• Abnormal diagnostic testing results
• The patient's responses to care and treatment(s)
• Fluid status including all intake and output
• Any unusual occurrences, variances, incidents and accidents
• Special treatments and patient responses such as the administration of blood
• Any consults and referrals and
• Changes in the plan of care and/or doctor's orders

Facilities use standardized methods of reporting to insure the completeness of these end of shift reports, as well as patient transfer reports and patient discharge reports.

Some standardized change of shift "hand off" reports, as recommended by the Joint Commission on the Accreditation of Healthcare Organization, include:

• SBAR
• ISBAR
• BATON
• The Five Ps and
• IPASS

SBAR stands for:

• S: Situation: The patient's diagnosis, complaint, plan of care and the patient's prioritized needs
• B: Background: The patient's code or DNR status, vital Signs, medications and lab results
• A: Assessment: The current assessment of the situation and the patient's status and
• R: Recommendations: All unresolved issues including things like pending diagnostic testing results and what has to be done over the next few hours

ISBAR stands for:

• I: Introduction: The introduction of the nurse, the nurse's role in care and the area or department that you are from
• S: Situation: The patient's diagnosis, complaint, plan of care and the patient's prioritized needs
• B: Background: The patient's code or DNR status, vital Signs, medications and lab results
• A: Assessment: The current assessment of the situation and the patient's status and
• R: Recommendations: All unresolved issues including things like pending diagnostic testing results and what has to be done over the next few hours

BATON stands for:

• B: Background: Past and current medical history, including medications
• A: Actions: What actions were taken and/or those actions that are currently required
• T: Timing: Priorities and level of urgency
• O: Ownership: Who is responsible for what? and
• N: Next: The future plan of care

The Five Ps are:

• P: Patient: The patient's name, age, gender, location and other demographic data
• P: Plan: Patient diagnosis and plan of care
• P: Purpose: The rationale for the care plan
• P: Problems: Things that are different, abnormal or unusual and
• P: Precautions: Risks and things that may change and/or become unusual for the patient

IPASS stands for:

• Introduction: The introduction of the nurse, the nurse's role in care and the area or department that you are from
• P: Patient: The patient's name, age, gender, location and other demographic data
• A: Assessment: The current assessment of the situation and the patient's status
• S: Situation: The patient's diagnosis, complaint, plan of care and the patient's prioritized needs and
• S: Safety concerns: Physical, mental and social risks and concerns

Using Documents to Record and Communicate Client Information

Documentation is a form of written communication. A wide variety of documentation forms exist. Some of these forms include progress notes, admission forms, transfer forms to another level of care or service, referral forms, discharge forms, daily care flow sheets, graphic charts for vital signs, blood glucose level forms, intake and output forms, assessment forms, falls risk and skin breakdown assessment forms, narcotic records, patient teaching records, and other documents that are primarily used by other disciplines such as laboratory and diagnostic imaging reports.

Regardless of the differences among healthcare facilities in terms of the provision of care along the continuum of care and their specific documentation methods and forms, nurses must follow their own facility's policies, procedures and guidelines. For example, some facilities use problem oriented charting and others may use source oriented medical records; some may use multidisciplinary critical pathways or care maps and others may use discipline specific care plans like nursing care plans.

More extensive information about documentation was previously discussed with the "Integrated Process of Communication and Documentation" section.

Using Approved Abbreviations and Standard Terminology When Documenting Care

As previously detailed with the Integrated Process of Communication and Documentation, there are a number of abbreviations that can jeopardize client safety because they can be interpreted differently among healthcare providers, therefore, the Joint Commission on the Accreditation of Healthcare Organizations and common sense mandates that only accepted and approved abbreviations and terminology are used for documentation. For example, the abbreviation "MS" is NOT an approved abbreviation because "MS" can be interpreted as multiple sclerosis, morphine sulfate and magnesium sulfate. All healthcare facilities are required to have a formalized list of unacceptable abbreviations that cannot be used because they are problematic and can lead to errors and confusion.

Performing Procedures Necessary to Safely Admit, Transfer or Discharge a Client

The continuity of care is facilitated with the safe admission, transfer and discharge of clients.

An admission is defined as the first, initial client contact. A transfer, in the context of this review, is defined as the movement of the client from one area to another area within the same healthcare facility; and a discharge is defined as the cessation of care and services to a client. For example, a client can be discharged to another healthcare facility or to the community.

Admissions, transfers and discharges of clients require that the sending and receiving persons, such as a registered nurse, communicate in writing and orally at times about the client and their current status.

Upon admission and transfer, the client will be assessed and planning will begin and done by the person receiving the client. The admission process typically includes orienting the client and/or the significant others to the healthcare setting, a complete review of the client's bio-psycho-social status and needs, medication reconciliation, a complete and thorough assessment, and giving the client or significant other information such as HIPAA information, patient rights and responsivities, and the complaint process in addition to other admission essentials.

Upon admission and transfer, the sending area will provide the receiver of the patient with complete information about the client and their needs. Some of this information can be done by the sending on an established form like a transfer form or the complete medical record to the receiving area or person.

Discharges, similar to transfers, involve the sender's communication and collaboration with the receiver of the client to insure that the particular discharge is appropriate for the client and meeting their needs and also to facilitate a smooth and seamless transition with the sharing of the client's medical information.

Following Up on Unresolved Issues Regarding Client Care

Unresolved issues can never be left unattended. The "loop" must be closed.

Nurses must report all unresolved issues up the chain of command and communication until resolution occurs. At times, unresolved issues can be followed up by the next shift of nursing team members and at other times they can be resolved with a simple telephone call. For example, nurses report unresolved issues during the change of shift report and they can also call the patient's doctor when laboratory values reveal significant changes and abnormalities.

RELATED NCLEX-RN MANAGEMENT OF CARE CONTENT:

• Advance Directives
• Advocacy
• Assignment, Delegation and Supervision
• Case Management
• Client Rights
• Collaboration with Interdisciplinary Team
• Concepts of Management
• Confidentiality/Information Security
• Continuity of Care (Currently here)
• Establishing Priorities
• Ethical Practice
• Informed Consent
• Information Technology
• Legal Rights and Responsibilities
• Performance Improvement & Risk Management (Quality Improvement)
• Referrals

SEE – Management of Care Practice Test Questions

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Alene Burke, RN, MSN

Alene Burke RN, MSN is a nationally recognized nursing educator. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. She got her bachelor's of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Association's task force on competency and education for the nursing team members.

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Source: https://www.registerednursing.org/nclex/continuity-care/

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