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standard work : Discharge - Patient Discharge Vital Signs & Focused RN Assessment

Standard Work for Patient Discharge Vital Signs & Focused RN Assessment

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  1. effective date:

    January 26, 2018
  2. content:

     

    Patient   Discharge Vital Signs & Focused RN Assessment Standard Work

     

    Last updated: 1/26/18

    Owner: PNSO Clinical Practice Cmte

    Performed   By: RN staff

    Version: 3.0

    Revised by: Acute Care Practice Committee

    Trigger:   Day of Patient Discharge

    Scope : All patient discharges from adult and   pediatric acute care

     

    Work

    Performed by

    Major Step

    Details

    Importance

    1

    RN

    Verify discharge order and planned time of   discharge

    Verify:

    •   Order in EPIC
    •   Facility & complex discharges with Case Manager
    •   Discharge to home with patient and family; include means   of transportation

    Use appropriate root   sources to obtain correct information, reduces waste from potential   misinformation

    2

    RN

    Use anticipated discharge time to determine   time for final focused assessment

    •   Schedule discharge focused assessment and vital signs to   occur ≤ 60 minutes prior to physical discharge (Check for need to remove IVs)
    •   Communicate time to PCA
    •   Acute changes require LIP assessment to verify that this   is a safe discharge
    •   Allows time to gather patients belongings and plan care

    3

    RN

    Delegate obtaining   vital signs to PCT or PCA. Complete focused discharge assessment

    •   Assess vital signs including pain assessment
    •   Focused assessment includes: Level of consciousness,   level of assistance needed with mobility and any specifics related to primary   diagnosis/reason for

    Hospitalization

    •   RN documents focused assessment completed by select field   in Epic on Discharge Checklist
    •   Abnormal VS are an early indication of acute change and requires RN action
    •   RN DOES NOT complete additional head to toe assessment   using flowsheet

    4

    RN

    Abnormal findings must be reported

    to   resident/LIP

    Report any concerning   findings in form of SBAR.

    Requires second tier decision making for   determination of “safe discharge”

    5

    RN

    Call report to   receiving facility

    •   Confirm they are expecting patient and have bed
    •   Use IDEAL format include all elements of discharge   assessment/VS.
    •   Tell facility estimated time of discharge
    •   Calling report prior to patient leaving unit reduces potential miscommunication errors r/t   facility readiness to receive.
    •   Receiving nurse will have current state   of patient’s condition to

    identify   future changes in status

    6

    RN

    Complete EPIC RN discharge checklist

    •   Review AVS & P/F education
    •   Check for belongings
    •   Check for prescriptions & home going supplies
    •   Complete discharge checklist
    •   Order wheelchair if needed

    Adherence to   associated standard work

    7

    RN and Transport team

    Transport safety check

    Enter room with transporters to give   bedside report for facility transfers

    •   Provides a shared understanding of baseline assessment
    •   Consistent assessment
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