My Nightmare Easter Weekend of 2003: The Importance of Documenting Patient History
To read the preceding chapter, Click Here.
Janis E. Harrison, RN, BSN, CWOCN, CFCN
My husband Daryl had gone in to a same-day surgery center for incisional hernia repair and possible "tummy tuck" after losing 85 pounds. We had searched for a good surgeon and opinions on any complications that might need to be considered, since Daryl had an ileostomy. We discussed whether or not mesh should be used, infection possibilities, and if he should have the skin tucked that was now loose from weight loss. One surgeon was not sure he wanted to tackle the task and possible complications. Another surgeon just said "sure, I can do that." Well, of course we wanted a competent surgeon; one with confidence and a little arrogance, but then, this was just a "simple" incisional hernia repair, right? WRONG!
Off we went for the surgery at about 4:00 in the morning. I had forgotten my cell phone and we had time to go back after it, but Daryl said, "You don't need it, we'll be home by noon." We were at the hospital 45 minutes early and got through admitting and pre-op without any problems. I went to the surgery waiting room to read a book and it seemed to be only 30 minutes when they came to get me for the consultation with the surgeon. According to him all was great and Daryl would be in recovery in 15 minutes.
Communicating with Providers for Improved Patient Care
I found him sitting in a recliner. They had given him some clear liquids to drink and his IV was out. He looked at me and said, "help me get dressed and we'll be home before 10:00." He stood up to put his leg into his pants, became pale and started to sweat. He sat back down and the nurse came after she was called. He described what had happened, then stated he had a very sharp pain under his ribs. The nurse gave him two pain pills and advised he should let them start to work before getting dressed. Every time he tried to lift his head he became pale and light-headed. I attempted to lay him back in the recliner but it would not latch into position, so I had to put the footrest on a separate chair to keep his head down.
We attempted to get him up again 15 minutes later and again he became pale and stated, "I'm going down hard this time." The nurses were passing him off for drama but I watched his blood pressure continually plummet after they decided to monitor him. When I pointed out his blood pressure was now down to 90/40, I suggested they should probably consider internal hemorrhage. I was asked to leave the room. I sat down refusing to go as no one was doing anything to help my husband. They said he WASN'T hemorrhaging because his abdomen is soft. I blurted out that he had lost 85 pounds and is laying with his head on the floor so it has to be all gathering up under his ribs and we needed to have a doctor evaluate him at this time. The doctor from anesthesia came in and ordered two intravenous accesses and some blood work immediately. Daryl's hemoglobin had dropped and they could get only one IV accessed for fluids. They were watching the monitor when Daryl said, "This time I'm going to die."
The last blood pressure I saw was 37/0 as I told them they better call a code while looking at my very pale, gray husband's eyes roll back in his head, and they made me leave the room.
More on that later.
Listening to Patient History to Formulate a Plan of Care
All documentation and assessment should start by listening or checking the patient's history and the pertinent components that can affect the plan of care you choose for your client. In wound care, the first thing we would like to know after gathering the demographic information is the wound etiology and the diagnosis given by the physician. It is important to know how long the client has had the wound and try to pinpoint the date. We like to look at the medications such as corticosteroids, immunosuppressants, and cancer medications as they may have a direct effect on the healing process. Then gather and document any other comorbid conditions such as malignancy, diabetes, cardiac complications, and respiratory or renal conditions. A full understanding of the patient's physical environment can bring to bear factors for or against successful healing. It is imperative the physician has this information available in the outpatient chart so a plan of care can be formulated. Other assessment information that is pertinent:
- Are there signs or symptoms of infection, either systemically or in the wound?
- Has a Pressure Ulcer Risk assessment been completed? Have these risks been addressed?
- Is there compromise to circulation or tissue perfusion?
- What is the patient's nutritional and hydration status?
Check to see if there is any family or caregiver support, financial limits, or problems with getting access to resources such as travel to and from appointments, getting dressings, or need for home care. Check mental status and for memory capacity. Good communication skills doesn't just mean a sixth grade reading level. We tend to forget that in our world of educated medical professionals. It is great when a family member shows interest in becoming an integral part of the care plan construction and execution. They can add accuracy to the history and provide the vehicle by which the plan of care will be carried into the home. We also like to know what therapy has been tried in the past and many times it is the family or caregiver that can tell us better than the client. Our healing success is guided by the education we give to these individuals along with their feedback and response. Don't push them out.
It is important to keep good documentation tools readily available at the point of care so nothing is forgotten or omitted. Reimbursement of our services is formulated by the documentation of all factors gleaned from our initial assessment. Think of yourself as the detective in a murder mystery. Each documented clue becomes a possible coding thread for reimbursement.
About the Author
Janis Harrison is the CEO and owner of Harrison WOC Services, LLC, which offers contractual Wound, Ostomy and Continence (WOC) services for hospitals, long-term care facilities and home health across Northeast Nebraska. Harrison has had numerous poster published, is a writer for Advanced Tissue's newsletter and is currently involved in developing health care documentation applications for WoundRight Technologies, LLC.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.