clinical documentation

 by Gillian Robinson

Clinical Assessment Recognises Subtle Changes

Our eyes see what is familiar and what they expect to see.  Are we good at picking up subtle changes through your assessment processes and acting on them appropriately?  The ability to see the less than obvious is essential when responsible for clinical assessment as you won’t act on those things you haven’t noticed.

On the 5th July I presented a full day seminar on a range of topics to Nurses working in aged care.  During the day I made what should have been an obvious change but I have no doubt it wasn’t noticed by all.  In the morning I wore a dress with a white jacket. In the afternoon I’d changed the dress for one of a different colour and pattern but retained the white jacket.  I made the change during the lunch break.

When I entered the room after the lunch break three people commented straight away.  I saw a small number of puzzled looks but those nurses didn’t say anything.  Others didn’t seem to notice and didn’t make comment.  We had three distinct groups.  Those that notice and comment, those that notice but don’t comment and those that don’t notice and therefore don’t comment!  Which are the nurses you’d feel safest with if it came to performing a clinical assessment on you on an ongoing basis day after day?  Which differences would they notice and which wouldn’t get a second glance. Which changes would be commented on?

We need a mix of ‘detail’ thinkers and ‘big picture’ thinkers to see everything that occurs.  Equally these two groups of people can complement each other.  Working separately they will each only see part of what needs managing.  Some over think and others don’t seem to think or reflect.  Awareness of how the members of your nursing team work and think could be important in supporting you to minimise risk resulting from subtle changes occurring which may not have been addressed.

It may be beneficial to review personality types to see how your team are working separately or collectively to ensure the best outcome for residents in their care. This increased recognition of each others natural thinking styles may also enhance the ability of the team to understand each other and consciously support others differences.  There are a raft of profiling tests however Myers Briggs has been around as a validated tool for a long time and may be a useful one for you and your team.

What subtle changes are occurring with your residents that you haven’t noticed?  Did you see the white dress in the morning change to a black one in the afternoon? If not, what else are you not seeing that could expose someone to risk?  Are any of your team seeing things but not saying anything because they don’t recognise it’s their responsibility or think someone else has commented?

in News
 by Gillian Robinson

Weight management goals in care planning

When care planning, the goals or objectives developed for each aspect of care need to be measurable.  This ensures you’re able to evaluate progress and determine whether the goal has been met or not.  The concern is making sure an appropriate goal is set.  While we look at this from a clinical perspective, we must always remember the resident as the central focus and director where they are able to provide input into what the care plan relays.  People have choice within their capacity and sometimes as nurses, we may not agree with a choice made by our patients / residents in aged care.

When guiding weight management goals from a clinical perspective, Liz Beaglehole, Registered Dietitian has offered the below guide.

Ideal weight range in the care process: 

Body mass index is still helpful in determining healthy weights for older adults.  A healthy BMI range for adults over 65 actually shifts upwards as compared to adults. So a healthy BMI for older adults has been found to be BMI – 22 – 27kg/m2. A BMI above 32kg/m2 would suggest obesity, a BMI below 20 suggests underweight, and below 18.5 is malnourished.

To work out the BMI: (weight/height²).  Example case:  height = 1.5m and weight = 45kg

  1. We need the height in metres and the weight in Kg.
  2. The height needs to be squared. So a height of 1.5m = 2.25 when squared.
  3. Then the BMI is the weight in Kg divided by the height²

Example:  weight = 45kg divided by 2.25 = BMI of 20kg/m².  This is regarded as the lower end of ideal body weight and suggests the resident is underweight for optimal health.

An ideal body weight for some who is 1.5m tall would be a BMI range of 22 – 27 so a weight range of min 50kg up to around 60kg.  Basically to work out ideal body weight just enter different weights into the BMI calculation until you get to the BMI of at least 22 and then again to a BMI of around 27.

The ideal body weight may differ to the GOAL weight.  The goal weight may be something that is set when the BMI is outside the ideal range but some weight changes are desirable.  The goal weight is more useful and practical as it considers the weight history of the resident and the ability to achieve changes in weight.  For example, a resident may be underweight with a weight of 42kg (BMI= 18.6) but they have been this weight for the past year.  Ideally they would gain weight to 50kg, but this is unrealistic.  The goal weight therefore becomes either weight stabilisation at 42kg or a slight weight gain to 44kg.  This would still mean the resident is underweight but is realistic in what can be achieved.  If the initial goal weight is achieved, a second goal weight may be identified.  This may be to stabilise weight at 44kg or to gain to 45kg.  etc…

This can work for overweight residents too.  Using the same example height of 1.5m.  Someone who weighs 78kg has a BMI of 34.6, and is obese.  However, realistic weight loss to within the ideal body weight range would suggest the resident would need to lose around 18 – 28kg, which is completely unrealistic and would never be suggested for aged care.  A more realistic GOAL weight would be weight stabilisation and then some weight loss.  5% weight loss can improve many health outcomes and this would be a realistic target.  Weight loss of 5% is still around 4kg, which is possible but still difficult.

Article contributed by: Liz Beaglehole (NZ Registered Dietitian), Canterbury Dietitians

in News
 by Gillian Robinson

Village Manager – Chatswood Retirement Village

I have found that having Gillian’s (the HCSL) system available has been a huge help to our village. Documents are easily accessible at my fingertips and it hasn’t taken long to memorise some of the codes for the more frequently used ones.

 

If we are having trouble finding a document or we want to make any adjustments, Gillian is always very accommodating and helpful. She is easily contacted by telephone or email and if she is busy, always gets back to me as soon as she is able to. I particularly like that if I want to type into a document, Gillian makes this available.

 

When the documents are due for updating, Gillian takes care of this, printing all of the documents and putting them into new folders for us. She even delivers them personally, which is always a pleasure. I find Gillian very approachable and extremely knowledgeable and happy to share her knowledge.

 

Gillian assists us with our training requirements by coming to Chatswood and going through the annual compulsory subjects with myself and my staff. She is great at presenting and the passion about her work shows in the way she shares her own experiences with us.

 

I look forward to our continued working relationship.

Kyla Hurley – Village Manager

January 2017

in Testimonials
 by Gillian Robinson

Residential care education workshops

We provide a number of aged residential care education workshops throughout the year. Topics include:

  • Code of Rights (includes Advocacy, Informed consent, Privacy, Advance Directives, Open Disclosure, Complaint management)
  • Conflict Resolution
  • Cultural and Spiritual Safety
  • Restraint (including Enablers) safe practice and minimization
  • Challenging behavior management (including de-escalation strategies)
  • Clinical documentation and managing clinical risk
  • Quality and Risk management
  • Infection prevention and control surveillance
  • Death and dying – loss and grief
  • Leadership skills for managers and nurses
  • Intimacy and sexuality in the elderly
  • Skills for orientation ‘buddies’
  • Stress management and
  • Advanced communication skills

The workshops will initially be held in Christchurch however could be presented in other areas if the interest is high enough. Please feel free to contact us with your requests.

in News / Services
 by hcsl

Policies & Procedures

More Time HCSL

Residential Care Services policies and procedures – customised to reflect to levels of care provided

HCSL is still the only New Zealand provider that, along with our software offer fully customised (Site by Site) up to date. New Zealand compliant policies & procedures, so you don’t have to update, edit or create them yourselves.

The services offered includes access to customised ‘ready to use’ policy and procedures under license with online access.

New Zealand compliant policies & procedures
Customised for you.

Documents HCSL

The HCSL solution gives you access to Policies and Procedure documents for the following catagories.

  • Consumer Rights

    (CR) 32 Documents

  • Service Delivery

    (SD) 23 Documents

  • Learning & Development

    (HR) 72 Documents

  • Food Service

    (FS) 38 Documents

  • Clinical Service

    (CS) 166 Documents

  • Safe & Appropriate Environment

    (SAE) 59 Documents

  • Entry To Service

    (Entry) 25 Documents

  • Infection Prevention & Anti-microbial Stewardship

    (IPAS) 38 Documents

  • Village

    (V) 33 Documents

  • Organisational Management

    (OM) 37 Documents

  • General Documents

    (GD) 26 Documents

  • Clinical Resources

    (Clinical) 1 Documents

  • Community

    (HCSS) 27 Documents

  • Meals On Wheels

    (MOW) 9 Documents

Current to October 2021

Want To Know More?

Contact Us
in Policies & Procedures
 by Gillian Robinson

Falls – When is a fall not a fall?

Is a slip off a chair or off the side of the bed onto the floor a fall?  Is a ‘controlled lowering’ by a staff member of a resident to the floor a fall?

When recording adverse events such as falls, it’s important for the purposes of consistent reporting and bench-marking that the same definition is used to define a ‘fall’.  We suggest using the definition provided by the World Health Organisation (WHO) which states “A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level.”  The WHO falls prevention guidelines also report that “Globally, falls are a major public health problem. An estimated 424 000 fatal falls occur each year, making it the second leading cause of unintentional injury death, after road traffic injuries.”  

Working in aged care related services means you are interacting on a daily basis with those in the high risk category for falls. WHO also report for example, in the United States of America, 20–30% of older people who fall suffer moderate to severe injuries such as bruises, hip fractures, or head traumas. The Health Quality and Safety Commission New Zealand report “for every fall in hospital, there are five in aged residential care and another 40 at home and in the community. Between 2010 and 2012, a total of 200 people fell while in hospital care and broke their hips.“

The HCSL QA online bench-marking includes tracking of falls and falls related injuries so educating your staff to become familiar with the definition is important in ensuring data collected is accurate. Accurate data measurements also allow you to be aware of your start point for quality improvement projects which can then be measured at the end of a project to measure the degree of improvement.

In answer to the questions posed at the start of this article, if we apply the WHO definition, then both should be classified as falls.  For those of you using the HCSL policy and procedure system, refer to the Falls Prevention Programme (document CS19) for more information on falls prevention.

in News
 by Gillian Robinson

Pressure Injuries – ACC may be able to help

‘Pressure injury’ according to ACC can be classified in some instances as a ‘treatment related injury’ and therefore you may have the option of gaining support / assistance from ACC in relation to treatment of the pressure injury. In their 2011 fact-sheet, ACC noted “Pressure areas are a significant source of treatment injury claims and impact on both patient morbidity and mortality (1). Between July 2005 and March 2011, ACC accepted 506 claims for pressure areas, and notified 45 as adverse events to the Ministry of Health”.

As pressure injuries are a key focus for Ministry of Health (MoH) this year, auditors will be looking closely at the documentation around identification, management, treatment / care planning and evaluation of these events. Ensure you have comprehensive evidence of your clinical management processes.

Also remember when you log a pressure injury into the adverse event reporting system, you include the stage of the pressure injury. In the HCSL QA online system click ‘pressure injury’ in the ‘type of event’ box and then in the box directly under that, you can record the additional detail of the stage of the pressure injury.

The required MoH notification forms can be found here.  You will need the resident GP to complete a ACC45 form. Then contact ACC and rather than asking for what you want, ask what they can do to help. If you ask first, you may be missing out on something they could have provided access to.

For more information on seeking support contact Assistant ACC directly or the ACC Contracts Manager – CDHB Email: Leanne.davie@cdhb.health.nz

in News
 by hcsl

Electronic records and computer use in residential care facilities

I remember years and years ago hearing about the coming of the paperless society!  Do you recall that?  Have we achieved it?  If anything, we’re surrounded by more and more paperwork.  I receive enquiries on a regular basis from disgruntled nurses that are bogged down in paperwork and wanting to know if there is a simpler way to do things that will allow them time to get back to hands-on nursing; spending time with their residents.

I’m more than happy to help you with freeing up your time and still achieve all the necessities of documenting service provision.  One way to do this is using smart computer software.  I realise that up until recently our industry has not been ready for this however with the surge in uses of Facebook and other social networking sites, computers are not as intimidating as they once were!

I’m committed to getting your nurses back on the floor while working on the basis of continuous improvement and providing excellence in care based on evidence based practice.  In order to help me develop the tools you need I’d appreciate you taking a few minutes to complete this quick and simple survey.

Thank you for your time and look forward to getting a solution that will allow you to get out of the office and back to your residents!

in News