Care Plan Storyboards
This is January 2008 material where the PC committee stopped working on it. It can be further developed in the 2010 project.
Care Provision Domain Models: Explanation & Guidance Care Plan
Storyboard: Pneumonia Care Plan Generation:
Purpose: This storyboard illustrates a pneumonia care plan containing Problems, Orders/Interventions and Expected Outcomes.
Precondition: Med surg nurse admits Mr. Everyman, an 86 year old male, with an admission diagnosis of RLL pneumonia. He was seen in an urgent care clinic with complaints of a recent onset chest discomfort, shortness of breath upon exertion and general malaise. A CXR done in the clinic showed pneumonia. Dr. X (the family practice physician seeing the patient in the clinic) has written (paper) admission orders, and assigned an admitting diagnosis of RLL pneumonia.
The following orders are placed by the physician: Admit to general Medicine Service of Dr. X. Diagnosis: RLL Pneumonia Condition:Stable Vital Signs q4h IV NS at 75cc/hr. Regular Diet as tolerated Activity as tolerated Notify me if temp above 101 degrees F. Rocephin 1 gm IV q 24 hours CBC in AM CXR in AM Blood Cultures if temp above 101 degrees F. Oxygen per nasal cannula at 3 liters per minute Maintain oxygen saturation >90%
ADT information is in the system.
The unit clerk enters the dx inform the admitting orders “RLL Pneumonia” A guideline for pneumonia exists in the system.
Events: The nurse logs into the system and sees the following problems are suggested based upon the Pneumonia guideline: (Need to do activity diagram) Risk for hypoxia (Observation of “Hypoxia” with Mood Code of “Risk”) Risk Ineffective Airway Clearance Risk for Falls related to low oxygen saturation
Susan – check Risk of in TermInfo Discuss Risk/Event Moods with Problem modeling
She selects the above problems which places them on the problem list and adds: Fluid Volume Deficit risk
The following nursing orders are suggested by the system based on the selected problems and physician admitting orders. Out of bed with assistance (linked to risk of falls) Monitor I&O (intervention linked to all IV fluid orders) Educate regarding I&O (linked to IV fluid orders) Educate regarding OOB with assistance (linked to fall risk, linked to hypoxia) Monitor oral/nasal mucous membrane status (linked to oxygen administration via NC)
Nurse Sees suggested Goals/Expected Outcomes Maintain oxygen saturation >90% (risk for Hypoxia) Maintain Hydration (linked to Oxygen administration) (Susan – check this outcome) No falls (Linked to Falls Risk) Patient understands pneumonia disease process Temperature WNL within 48 hours. CXR reveals decreased consolidation in RLL.
Nurse accepts suggested goals/expected outcomes and adds the individual goal: Maintain Nutrition
Patient normothermic, decreased consolidation revealed by CXR, oxygen saturation greater than 90% on room air. Patient discharged to home on oral antibiotics.
This is a storyboard form a IHE profile found on http://ihe-australia.wikispaces.com/file/view/PCC_Supplement_PCCP_v1.37.doc Patient Care has permission to use this material (permission from Dr. Peter MacIsaac, given on 7-11-2010)
Bob Glucose, a patient, is diagnosed with type II diabetes by his doctor, Dr. Planner. Dr. Planner creates a coordination plan in consultation with Bob, using best practice guidelines to inform the plan. The content of the coordination plan includes a schedule of tasks that are to be performed by the patient, by the doctor and by other health care providerAccountable Entities (the care team.) In Bob’s case the care team consists of himself, a diabetes educator, a podiatrist, an optician, a pharmacist and a psychologist. Tasks for Bob and Eencounters with the care team are scheduled in the plan with indicated dates. Dr Planner submits a copy of the coordination plan in a shared registry/repository and notifies the care team of the new coordination plan. Dr. Planner gives Bob a copy of the coordination plan and asks him to make appointments with the providers identified in the plan. Each member of the care team, on receiving notification, acknowledges receipt of the notification. When Bob arranges an appointment, each member submits a simple “task report” document in a shared repository that indicates status of the relevant task in the plan. As Bob visits the care team members, each member submits another instance of the same simple document indicating the updated status of the plan. They may also choose to submit a record of encounter including any reports relating to the encounter in the shared repository. Six months later, Bob visits Dr. Planner for a regular review. Dr. Planner is able to access the shared repository and can see documents relating to Bob’s activities including visits to his care team. Bob has entered data relating to his self monitoring activities, with random blood glucose and weight records. There is a record of assessment, a diagram and a task report from the podiatrist. The task report indicates that the review task for podiatry is on track. There is an assessment and a task report from the diabetes educator indicating that there is an issue warranting further attention. There is no task report from the optician. Dr. Planner finds the assessment from the diabetes educator in the repository, counsels Bob on theencourages Bob to follow up with this coach onf the issues flagged by the diabetes educator in the assessment. He also asks Bob if he has visited the Optician, and Bob confirms that there was no appointment made. Dr Planner counsels Bob on the risks of retinopathy and advises him to visit the optician for a check as soon as possible.
the use case can be found on http://ihe-australia.wikispaces.com/PC+Storyboard+sandpit