Identifying, Communicating, & Documenting Patient Change in Condition
Presented by Tina Marrelli and Cathleen Armato
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Non-Financial: Tina Marrelli has no competing non-financial interests or relationships with regard to the content presented in this course.
Financial: Cathleen Armato is a share holder with Armato & Associates, LLC. Cathleen Armato receives compensation from MedBridge for this course. There is no financial interest beyond the production of this course.
Non-Financial: Cathleen Armato has no competing non-financial interests or relationships with regard to the content presented in this course.
This course provides team members with the fundamental framework about effectively identifying, communicating, and documentation a change in a patient’s condition or status. One fundamental standard in home care and hospice is that the physician has a unique and multifaceted role in regards to orders, care, and the treatment plan. Care and orders are based on the patient’s care needs and findings, usually at the initial assessment. As patient’s care and status improve, decline, or otherwise change, physicians are notified and the plan of care may change, based on orders. These processes are a part of the care planning, nursing or problem-solving cycle. There are a number of standards of practice, best practices, and regulations about these components of care and this course provides examples and key strategies for effectively addressing a patient change in condition.
Meet your instructors
Tina Marrelli
Tina Marrelli is the president of Marrelli and Associates, Inc., a publishing and consulting firm working in home care for more than 30 years. Tina is the author of 13 books, including the Handbook of Home Health Standards: Quality, Documentation, and Reimbursement (6th edition, 2018). Other books include A Guide…
Cathleen Armato
Cathleen Armato is an experienced executive with 22 years in the home care and hospice industry. She has served in various roles during that time, including VP of operations and chief compliance officer for a nationwide healthcare provider. In 2012, Cat became a consultant. Since that time, she has assisted multiple…
Chapters & learning objectives
1. Defining a Patient Change in Condition
Medicare is a medical insurance program and as such, the physician is responsible for the oversight of the care. Just as in a hospital setting, home care must be provided with physician oversight. This chapter provides a definition and explanation of a change in condition.
2. Identifying and Recognizing a Patient Change in Condition
When a patient experiences a change in condition, it is a pivotal time. Negative changes from the patient baseline can frequently indicate the patient is “at risk” and may result in the need for urgent care. Recognizing the changes and effectively communicating these changes may help the patient stay in their preferred care setting – their home. This chapter reviews tools and other strategies for identifying change in condition.
3. Communicating a Patient Change in Condition
While in home care, there are a number of critical times where patient’s may be “at risk” from a lack of clarity or communication related to their status. These may include changes in care settings, such as a transition from one care setting to another, changes in clinicians (“hand-offs”), change in the environment of care (after a fall or other incident), and other untoward findings or incidents that place the patient’s health at risk. A patient case scenario will be demonstrated for process review.
4. Documenting Patient Changes in Condition
Documentation is a communication tool in itself. It tells health care providers what is happening with a patient at a point in time and over time. In addition to being the most reliable source of information, good documentation is for the health care providers protection as well. Sadly, nurses, therapists, and other team members are not immune from judgement or lawsuits. The best protection is appropriate documentation of both the change in condition and the communications following the observed changes. This chapter will review models that can be used to document changes in patient condition.
