Discharge medications when to contact the primary

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discharge medications, when to contact the primary care provider, condition of discharge, and time of discharge
Home Care DocumentationoIn 2000, Outcome and Assessment Information Set (OASIS) was mandated by the federal government. OASIS tool accurately measures the patient’s status during home care. This allows for a basis of measurement for patient outcome. Long-Term Care DocumentationoThe Resident Assessment Instrument (RAI) governs documentation in long-term care settings.The goal of RAI is to optimize the resident’s quality of care and quality of life. The RAI is a very comprehensive assessment tool. Written Handoff SummaryoA handoff, or transfer or care for a patient from one health care provider to another, significantly increases the risk of errors. Handoffs do not only occur during a shift change, but also when a patient is transferred from one area of the hospital to another. oTo minimize potential errors from lack of information, it is important to provide specific assessment on a written transfer in addition to a verbal report.ReportingoReporting occurs at handoffs, during patient rounds, during patient andfamily care conferences, and when calling or texting a provider to report a change in status or provide requested information. oSituation, Background, Assessment, and Recommendations (SBAR) ModelSBAR improves communication between health care professionals. Situation: State concisely why you are communicating.Background: Describe the circumstances leading up the current situation.Assessment: Give objective and subjective data pertinent to the situation.Recommendation: Make suggestions for what needs to be done to manage the difficulty.
Telephone CommunicationoSometimes a phone is necessary if a significant issue occurs. It is important to document the call, including the time, who was called, what information you gave to the primary care provider, and what information you received. Patient Rounds and Conferences oShift handoffs can occur with the patient present.oWhen rounds include the patient, your goal as a nurse is to include the patient in planning goals and care.

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