1 THB (MR600) Last Review July 2012

Copyright © 2012. Nursing and Midwifery Directorate, NHS Tayside. This publication can be used or reproduced including photocopying, for non-commercial purposes. We request that the source and Copyright owners be acknowledged and that the material is not substantially altered in any way. Applications for use outwith these terms should be forwarded in writing to the Nursing and Midwifery Directorate, NHS Tayside, Level 9, Ninewells Hospital, Dundee, DD1 9SY.

CONFIDENTIAL Multidisciplinary Record of Care

Core Data Set

Please do not view these records unless you have the patient’s consent

Affix sticker if patient has opted into “Butterfly Scheme”

Admission/Transfer/Boarding Destination 1

Destination 2

Destination 3

Destination 4

Hospital

Ward

Transfer date & time

Patient & relatives informed?

Completed by – Initials

Readmission History

Date Date Date Date

Hospital

Ward

Consultant

PATIENTS/ CARERS ARE ASKED TO COMPLETE ALL SECTIONS HIGHLIGHTED IN BLUE IF ABLE TO DO

SO

Core Data Set completed by Patient ���� Carer ���� Nurse ����

Pre-assessment (excluding greyed out sections) Initials of Nurse Date/Time Admission unit /ward Initials of Nurse Date/ Time Designated ward Initials of Nurse Date/ Time If unable to complete in full please specify reason ____________________ Initials of Nurse Completion date/time

2 THB (MR600) Last Review July 2012

Copyright © 2012. Nursing and Midwifery Directorate, NHS Tayside. This publication can be used or reproduced including photocopying, for non-commercial purposes. We request that the source and Copyright owners be acknowledged and that the material is not substantially altered in any way. Applications for use outwith these terms should be forwarded in writing to the Nursing and Midwifery Directorate, NHS Tayside, Level 9, Ninewells Hospital, Dundee, DD1 9SY.

Multidisciplinary Record of Care Register of all personnel writing in Core Data Set

All members of staff who are using this Core Data Set should complete this section once.

Name

Job title Ward Hospital Signature Initials

3 THB (MR600) Last Review July 2012

Copyright © 2012. Nursing and Midwifery Directorate, NHS Tayside. This publication can be used or reproduced including photocopying, for non-commercial purposes. We request that the source and Copyright owners be acknowledged and that the material is not substantially altered in any way. Applications for use outwith these terms should be forwarded in writing to the Nursing and Midwifery Directorate, NHS Tayside, Level 9, Ninewells Hospital, Dundee, DD1 9SY.

Multidisciplinary Record of Care

Register of all personnel writing in Core Data Set All members of staff who are using this Core Data Set should complete this section once

Name

Job title Ward Hospital Signature Initials

4 THB (MR600) Last Review July 2012

Copyright © 2012. Nursing and Midwifery Directorate, NHS Tayside. This publication can be used or reproduced including photocopying, for non-commercial purposes. We request that the source and Copyright owners be acknowledged and that the material is not substantially altered in any way. Applications for use outwith these terms should be forwarded in writing to the Nursing and Midwifery Directorate, NHS Tayside, Level 9, Ninewells Hospital, Dundee, DD1 9SY.

Abbreviations

This abbreviation list has been approved by NHS Tayside and is supported by NHS Tayside policy for Records and Record Keeping for Registered Nurses, Midwives and Specialist Community Public

Health Nurses.

There are blank spaces incorporated and each clinical specialty can write their own relevant abbreviations in full below and therefore can be included within the record.

A&E

Accident and Emergency IM Intramuscular

BG

Blood Glucose INR International Ratio

BMI

Body Mass Index ICU Intensive Care Unit

BP

Blood Pressure IV Intravenous

CAD Care as described on…Date…..(date must be stated)

LA Local Anaesthetic

CCU

Coronary Care Unit NIR No Intervention Required

C

DIFF

Clostridium Difficile MUST Malnutrition Universal Screening Tool

CHI Community Health Index MRSA Methicillin Resistant Staphylococcus Aureus

CPR

Cardio Pulmonary Resuscitation MSSU Mid Stream Specimen of Urine

CSU Catheter Specimen of Urine O2 Oxygen

CVA Cerebral Vascular Accident (Stroke) PEG Percutaneous Endoscopic Gastrostomy

CVC Central Venous Catheter PICC Peripherally Inserted Central Catheter

DOB Date of Birth PMH Past Medical History

DOSA Day of Surgery Admission Unit PVC Peripheral Vascular Catheter

DVT Deep Vein Thrombosis SBAR Situation Background Assessment Recommendations

ECG Electrocardiogram SEWS Scottish Early Warning Score

GA General Anaesthetic SP02 Saturation of Peripheral Oxygen

HAN Hospital At Night TPAR Tayside Prescription Administration Record

HDU High Dependency Unit TTO’s Tablets to Take Out

ICT Infection Control Team VTE Venous Thromboembolism

5

1. GENERIC DETAILS

Hospital__________________________Ward____________Consultant___________________________

Date of Admission_________________ Time____________ Expected Length of Stay _______________

“Coming in to and Leaving Hospital Explained” patient information leaflet given �

Reason for Admission

Past medical History

Allergies (ensure recorded on TPAR)

Possibility of pregnancy? Y N

Patient details (affix label) Surname ….........................…………………..

Forename…………………………….….. DOB and CHI…………………………….. Address…………………………………………… …………………………………………………….. …………………………………………………….. Postcode…………………………………………. Sex…………………

GP Details (affix label) GP Name……………………………………… Address……………………………………….. …………………………………………………. ……………………………………….………… Postcode……………………………………… Telephone Number…………………………..

If address different on admission, please state: ________________________________________

________________________________________________

Daytime Telephone Number _____________________ Evening Telephone Number _____________________

Preferred Name__________________Title________Age______Marital Status____________________ Ethnic Origin____________First Language_____________Other:_________Interpreter Required Y N Do you/the patient use other methods of communication? Y N Sign Language � Braille � Makaton � Talking Mat � Other:_____________________ Religion___________________ Do you have any religious/spiritual needs whilst in hospital? Y N specify _______________________________________ You/the patient may have any worries/concerns whilst in hospital, would you like the opportunity to talk through your concerns with a member of the Spiritual Care Team? Y N

Date Spiritual Care Team Contacted __________________________ Date Interpreter Contacted __________________________________

Emergency Contact/s (To whom any information can be disclosed to/ and or Next of Kin)

1st. Name _______________________ 2nd. Name _______________________

Relationship _______________________ Relationship _______________________

Address _______________________ Address _______________________

__________________________ ___________________________ Telephone Number Telephone Number ________________________________________ ________________________________________

1st Contact aware of admission: Y N If No Date & time notified of admission______________________

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2. CONSENT/CAPACITY: Whilst undertaking the patient’s clinical assessment, if you have any concerns regarding the patient’s capacity and ability to make healthcare decisions, please refer to medical staff for assessment under the Adults with Incapacity (Scotland) Act 2000 and document your actions within the nursing notes. Information about the patient can be obtained from relatives/carers including legal guardians or staff in the patients regular/ previous care setting. Relatives and carers cannot make decisions for patients except in certain circumstances where they hold Welfare Guardianship or Power of Attorney extending to health care decisions under the Adults with Incapacity (Scotland) Act 2000. Concerns regarding capacity? Y N Initial of Nurse Date/Time IF YES, Please complete below

Please circle Y N as appropriate Date/ Time

Initial

Has a Mini Mental State Exam (MMSE) been undertaken?

Y N Initial MMSE Score

Has the Consultant / Medical staff been informed?

Y N If No notify medical staff immediately AND for patients with Learning Disability or Dementia please notify Learning Disability Liaison Service or Dementia Liaison as appropriate of admission

Has Medical Incapacity form been completed?

Y N If No notify medical staff to undertake Full Capacity Assessment

Power of Attorney

a) Welfare?

Y N Activated: Y N Contact details:

b) Financial affairs? Y N Activated: Y N Contact details:

Living Will/ Advanced Directive?

Y N Verification Y N

3. DISCLOSURE OF INFORMATION: Is there anyone else (other than emergency contacts) that you/the patient consent to receive information with regards to your/their healthcare? Y N Name/s & contact number/s

Other healthcare/social/housing providers? Y N If YES please specify _____________________

___________________________________________________________________________________________________________________

What information are you happy for us to share? e.g. a general statement like ‘doing well’ or specific details for example results of tests or diagnosis

Is there anyone you do NOT wish us to disclose any information to? Y N Full name/s & relationship

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4. ASPECTS OF SELF CARE:

Are there any aspects of self-care you/ the patient would like to be involved in whilst in hospital: for example taking own medication, stoma care, wound care, exercise regime? Y N

Please specify: _______________________________________________

Would you/the patient like anyone to provide any aspects of your care whilst in hospital: for example personal care, assistance at mealtimes? Y N Please describe details of who, and what aspects of care to be provided below

Do you/ the patient have an Anticipatory Care Plan? (see Guidance) Y N

5. SOCIAL CIRCUMSTANCES 5a. Dependants: Do you/ the patient provide care or support for someone? Y N

IF YES, SPECIFY : Relationship to you/the patient Arrangements made for care of pet/s (If applicable, please state below) ___________________________________

Do you have any other dependents? Y N IF YES, SPECIFY : What arrangements been made for dependant/s? (Please give details )

5b. Home Environment Lives alone Y N Type of accommodation e.g. own home / care home/ group home etc. (specify) Are you planning to return to this accommodation after you leave hospital? Y N If NO what plans have you made? _______________________ ___________________________________________________________________________ Does the property you will be returning to have : External stairs Y N Internal stairs Y N Wheelchair access Y N N/A Toilet :- Upstairs Downstairs Bedroom:- Upstairs Downstairs

Are you able to cook, or have someone who can cook for you? Y N Are you able to do your own shopping/have someone that can shop for you? Y N

8

5c. Significant Other(s) Involvement In The Patient’s Care

Do you/the patient have someone who provides care or support for you? Y N IF YES, SPECIFY BELOW Name of main carer ___________________________ Relationship ___________________________ Please describe care provided by main carer Key holder: Y N

6. COMMUNITY CARE PROVISION

Do you / the patient have any of the services below?

Please circle

Specify Care

Contact Details

Days provided

Number of visits per day

Date phoned to be restarted

Initial

Home Care Package

Y N

District Nurse

Y N

Care manager /Social worker

Y N

Nurse Specialist e.g. Continence / Respiratory Nurse

Y N

Meals Delivered

Y N

Day care

Y N

Other (specify)

Y N

Phone to restart services if the patient is able to go home on existing package of care. Complete the grey section. Please note; services may be stopped following admission and therefore a re-referral will be required. If circumstances have significantly changed then refer to “Referral to Social Work/District Nurse Form” THB(MR)565 and document in the discharge plan

9

7. LIFESTYLE, WELLBEING AND HEALTH PROMOTION

SMOKING

Are you a current smoker or use tobacco products? No smoking policy discussed? Are you interested in stopping smoking?

If YES refer to flow chart

Y N Y N Y N

SUBSTANCE USE Are you taking any ‘over the counter’ medications e.g. pain killers, herbal/ homeopathic remedies?

Are you taking any “recreational drugs” or inhalants? Would like help and support with addiction? If YES refer to Flow Chart

Y N Y N Y N

ALCOHOL Do you drink alcohol? Women: Do you regularly drink 6 or more units of alcohol on 1 occasion? Men: Do you regularly drink 8 or more units of alcohol on 1 occasion? Would like help or support to reduce/ stop drinking? If YES refer to flow chart

Y N Y N Y N Y N

WEIGHT MANAGEMENT (For patients with a BMI of above 25)

Does your weight impact on your day to day activities and your health? Are you comfortable with your current weight? If NO are you interested in receiving support to reduce your weight? If YES refer to Flow Chart on Tayside Nutrition Network(TNN)website at www.knowledge.scot.nhs.uk/taysidenutrition

Y N Y N Y N

EXERCISE /PHYSICAL ACTIVITY SCREENING How many days per week do you usually undertake a total of 30 minutes (accumulative) or more exercise/ physical activity? Please circle : 0 1 2 3 4 5 6 7 (Days) N/A If less than 5 days does this equal more than 2 and half hours of physical activity per week? Y N N/A If NO, would you like help or support to increase your activity levels? Y N N/A If yes – refer to flowchart on Tayside Nutrition Network(TNN)website at ww.knowledge.scot.nhs.uk/taysidenutrition

SLEEPING HABIT What time do you normally go to bed?

pm

What time do you normally get up?

_____________ am

How many hours do you normally sleep?

_______________hours

How many pillows do you use?

1 2 3 4 or more

Is there anything that regularly wakes you at night? e.g. pain/ needing the toilet

Y N (specify)

Do you take tablets to help you sleep (prescribed/herbal)?

Y N (specify)

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7. INFECTION CONTROL:

7a) MRSA SCREENING RISK ASSESSMENT (not for day cases)

Patient status:

Currently resident in a care home, institutional setting (Prison or Homeless Hostel) or transferred from another hospital?

Y N

History of MRSA colonisation/infection? Y N

Any wound/ulcer or invasive medical device which was present before admission to hospital? Y N

Being admitted to one of the following specialties? - please circle

Renal ICU/HDU Orthopaedics Vascular NB. If ‘yes’ to any of the above; obtain verbal consent from the patient. Consent obtained? Y N

Swabs – please circle Nose & Perineum (preferred option) or Nose & Throat And if applicable: Wound Invasive Device Site CSU 7b) INFECTION RISK STATUS

Has the patient

• Come back from abroad & or received hospital care abroad in the last month?

Y N

• Currently got diarrhoea &/ or vomiting which could be infectious? Y N

• Any suspicion of / or confirmed infection? Y N

• Any alert organisms: e.g.

C. difficile with diarrhoea? Y N Extended Spectrum Beta-lactamase (ESBL)? Y N Vancomycin Resistant Enterococcus (VRE) etc)? Y N MRSA? Y N If ‘yes’ to any question within 7b follow Standard Infection Control Precautions (SCIPs), and record in the

ongoing record the interventions taken with particular reference to Personal Protective Equipment (PPE) and patient placement (in a single room where possible, practicable and safe). Mark the traffic light document amber – if awaiting laboratory confirmation or red – when confirmed

If further advice required contact the Infection Control Nurse Mon-Fri (on-call Microbiologist / Infection Control Nurse at weekends via switchboard)

_______________________________________________________________________ If rescreened : Date /Time Swabs – please circle Nose & Perineum (preferred option) or Nose & Throat Wound Invasive Device Site CSU Date /Time Swabs – please circle Nose & Perineum (preferred option) or Nose & Throat Wound Invasive Device Site CSU Date / Time Swabs – please circle Nose & Perineum (preferred option) or Nose & Throat Wound Invasive Device Site CSU

11

8. ON ADMISSION TO EACH WARD/AREA

PATIENT MEDICATION DATE / WARD

Is the patient taking or prescribed any medications? Y N Y N Y N Y N

Patient has brought in own medicines? Y N Y N Y N Y N

Patient has brought in controlled drugs stored in the controlled drugs cupboard?

Y N Y N Y N Y N

Patient manages own medicines at home?

Y N

Y N

Y N

Y N

(If No, please circle relevant reason/s below and inform pharmacist) Carer manages medicines Manual dexterity problems

Co-ordination problems Cognitive impairment/confusion

Visual impairment Literacy/language difficulty

Swallowing difficulties Other (specify) ________________________

Does the patient understand what their medications are for? Y N

Y N

Y N

Y N

If the patient is registered with a pharmacy , please state, name of pharmacy & telephone number:

How does the patient usually obtain/order their medications : include compliance aid details ? (specify) _________________________________________

ORIENTATION Familiarised to ward environment

Y N

Y N

Y N

Y N

Identity band in situ

Y N Y N Y N Y N

Nurse call system explained

Y N Y N Y N Y N

Explain where toilet/wash facilities are

Y N Y N Y N Y N

Explain visiting/protected mealtimes/rest times and give “Your food and drinks in hospital leaflet”

Y N Y N Y N Y N

If NO to any of the above, please give reason why below and record in ongoing record of care-

Explain confidentiality of notes – does the patient wish to have access to their nursing record of care during their stay?

Y N Y N Y N Y N

VALUABLES Please circle below if applicable

Dentures Top / Bottom / Full Glasses / Contact lenses Hearing aid/s 1 2 Own clothing

Other (specify) ______________________ Walking aids (specify) ______________________ Patient’s funds and property procedure explained?

Y N Y N Y N Y N

Money/property to be handed over on behalf of patient for safekeeping? (Please refer and follow section 2.2.3 of Patient’s Funds and Property Procedure)

Y N Y N Y N Y N

12

NHS TAYSIDE PATIENTS’ FUNDS AND PROPERTY PROCEDURE

PERSONAL DISCLAIMER NOTICE LOSS OF PERSONAL EFFECTS

NHS TAYSIDE will not accept any responsibility for loss or damage to any article/personal belongings unless such article/personal belongings (including cash) have been handed over and accepted by NHS TAYSIDE for safe keeping and an official receipt issued.

Section A

If the patient, or patient’s representative, is unable, for whatever reason, at the time of admission to complete this form, please add the reason why, and ensure this is reviewed and updated. Reason:___________________________________________________________ Signature of staff recording reason: ___________________________________ Date:_____________ In the event of a patient or representative refusing to sign:- inform the patient/representative verbally that they are responsible for the their own belongings and valuables I __________________ (name of staff) have explained verbally to ______________ that all valuables and belongings are the patient’s/representatives full responsibility Signature of staff ____________________ Date_______________ Signature of staff witness _____________ Date_______________

Section B

I have been given the opportunity to read the above statement and I do /do not (delete as appropriate) wish to take advantage of the facilities provided for safe keeping of my personal belongings. Patient Signature* ____________________ Date: _______ Print Name: _________________________ Hospital: _____ Ward: *If being signed on behalf of a patient please enter your relationship with the patient, and your address. ** Delete as appropriate Relationship: ________________________ Address:_________________________________________ Witness to above signature: _________________________ Print Name: ______________________________________ Date: ___________________________________________

If section A has been completed or a review is required please enter review dates: (1) _____________ Sign:____________ Sign:____________ (2) _____________ Sign:____________ Sign:____________ (3) _____________ Sign:____________ Sign:____________

Note: It should be understood that when a patient is absent from the ward for treatment (e.g. x-ray; operation etc) the safe custody of their property which has not been handed over to NHS TAYSIDE for safe keeping, remains the patients’ responsibility. Arrangements may be available whereby property can be handed over to Nursing Staff for safe keeping during such periods.

13

‘MUST’ RISK ASSESSMENT. TO BE COMPLETED FOR ALL WITHIN 24 HOURS OF ADMISSION/OR AT PRE-ASSESSMENT (Refer to Food, Fluid and Nutritional Care Policy and Standard Operating Procedures) If patient NOT appropriate for ‘MUST’ Risk Assessment please specify reason:

If patient NOT appropriate for Generic Nutritonal assessment please specify reason:

Revew Date Review Date

Review Date Review Date Review Date Review Date

Height (m)

Stadiometer � Self reported height (if reliable) � Reported by carer �

Ulna Length (cm)

only required if height cannot be obtained

(not appropriate for learning disability)

Tape Measure (m)

(learning disability only)

Weight (kg)

Actual � Self- reported � Reported by carer �

Any unplanned weight loss over the last 3–6 months. If none, write 'nil')

Any unplanned weight gain (kg) over the last 3–6 months. (kg)

Are there any factors affecting weight? Yes � No �

Amputation Weight (kg) Corrected Weight (kg)

Oedema Wet Weight (kg) Corrected Weight (kg)

Ascites Wet Weight (kg) Corrected Weight (kg)

Plaster Cast Weight (kg) Corrected Weight (kg)

Other Specify

BMI (kg/m

2) from Ready Reckoner

‘MUST’ CALCULATOR

STEP 4 (add step 1, 2 and 3 together to give overall risk of malnutrition ('MUST' score)

Follow STEP 5 Management Guidelines

The ‘Malnutrition Universal Screening Tool’ (‘MUST’) is adapted and reproduced here with kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition).

BAPEN does not support the use of any product in particular.

Score 0 Low Risk

Score 1 Medium Risk

Score 2 or more High Risk

STEP 1 BMI score

(from Ready Reckoner)

+

STEP 2 Weight loss score

(from Ready Reckoner)

+

STEP 3 Acute disease

BMI kg/m

2 Score

greater than 20 (>30 obese) = 0

18.5 – 20 = 1

Less than 18.5 = 2

Unplanned weight loss in past 3-6 months (this includes obese patients)

% Score

less than 5 = 0 5-10 = 1

greater than 10 = 2

If patient is acutely ill and there has been or is likely to be no nutritional intake for more than 5 days

Score 2 Score 0 if not applicable

14

Date Oedema/ Ascites Yes/No

Weight Corrected Weight

B.M.I Step

1 Score

Step 2

Score

Step 3

Score

Step 4

Total

Score

Dietetic Referral Yes/No

Date for

Review

Initial

PLEASE COMPLETE WEIGHT CHART FOR LONGER STAY PATIENTS (THB(MR)566)

GENERIC NUTRITION ASSESSMENT – TO BE COMPLETED FOR ALL PATIENTS Criterion Y N Specify Intervention/Considerations

Has a Learning Disability Refer to/contact Learning Disability Liaison team immediately on 07740937309 Date :

Food allergies

Kitchen informed Relevant staff informed/ Included in safety brief Wrist allergy band in situ Allergies recorded in Nursing Notes and Drug Kardex Other, specify …………………..

�

�

�

�

�

Specific Cultural/ Ethnic/ Religious dietary requirements e.g. Vegetarian/Halal

Kitchen informed Halal/Vegetarian menu offered (if appropriate) Other, specify …………………..

�

�

Specific therapeutic dietary requirements e.g. Coeliac/Renal

Kitchen informed Other, specify …………………..

�

Able to make menu choices independently? Record Specific eating and drinking likes/dislikes

Give assistance if necessary to make menu choices, taking into account likes/dislikes Other, specify …………………..

�

Hydration needs If> 60 years of age - 30 mls/kg x body weight per day If 18-60 years of age - 35 mls/kg x body weight per day

Calculate daily fluid goal Offer regular fluids ( 8-10 drinks per day)

(or if applicable fluid restriction)

�

�

Cognitive Impairment/ Dementia/medical or psychological factors affecting nutrition

Unable to take 'adequate' food and/or fluid orally/ swallowing problems/poor oral health

Requires physical assistance with feeding, equipment, artificial nutrition supplements

If No to any question reassess each shift and record level of risk on traffic lights

If yes, please follow Step 5 Management Guidelines and Specific Nutritional Requirements Guidance, record level of risk on the traffic lights and in the on-going nursing record of care

15

MANDATORY RISK ASSESSMENTS TO BE COMPLETED FOR ALL PATIENTS ON ADMISSION/ OR AT PRE-ASSESSMENT. (please circle Y / N) PRELIMINARY PRESSURE ULCER RISK ASSESSMENT (PPURA) – within 6 hours of admission 1

Requires assistance and or aids to regularly relieve any pressure area (including heels/head etc) OR cannot / will not move independently OR on an operating table for > 2hrs?

Y N

2 Incontinent? – Urine or faeces in contact with the skin? Y N

3 BMI < 18.5 or > 40/ patient appears undernourished? Y N

4 Pressure ulcer grade 1-4? Y N

If Yes to any question; complete the Pressure Ulcer Prevention Treatment Plan and carry out the full Waterlow Risk Assessment. Theatre staff to complete Treatment Plan D. If No to any question follow treatment plan A which is :- encourage patient to check own skin condition regularly, re-assess PPURA each shift, and record on the traffic lights Treatment Plan A commenced Y N

FALLS RISK ASSESSMENT - within 24 hours of admission 1 History of falls prior to admission, or reason for admission Y N

2 Additional falls risk factors for this patient at time of admission? E.g. patient tries to walk alone but unsteady/unsafe, significant learning disabilities, Parkinson’s, CVA, acute confusional state, continence issues, visual impairment, medication, surgery etc.

Y N

If Yes to any of the above and considered to have significant risk factors or has a fall following admission, then complete falls prevention action plan.

If No to any question re-assess each shift, or if a change in clinical condition then record on traffic lights and completed full assessment

MANUAL HANDLING & MOBILITY ASSESSMENT - within 24 hours of admission

1. Is the patient fully mobile and walks without assistance on admission?

Y N

If No to the above question, please complete full manual handling and mobility action plan.

If Yes to the above question re-asses each shift, or if a change in the patients clinical condition, then record on traffic lights and complete a full assessment

Completed at Pre-assessment (PA) Initials of nurse Date Time Checked on Day of Surgery Admission Unit (DOSA) Initials of nurse Date Time

Completed on Admission Unit / Ward? Initials of nurse Date Time

Completed/ Checked on Parent Ward? Initials of nurse Date Time

RE-ASSESS EACH SHIFT/ AND FOR EACH ADMITTING AREA. USING THE TRAFFIC LIGHTS TO

RECORD THE LEVEL OF RISK IF THE PATIENT’S CONDITION CHANGES PLEASE COMPLETE RELEVANT ASSESSMENT AND

RE-ASSESS AGAIN EACH SHIFT

16

Discharge Plan - To be commenced on admission

Planned patient discharge date:

Actual patient discharge date: If delay please specify reason:

Patient informed of date Y N N/A Date Initials of nurse

Relative/carer informed of date Y N N/A Who was informed Date Initials of nurse

Patient Discharge Destination

Complete referral/s to early supported discharge /enablement team / District Nurse/ AHP or similar ( if applicable) Specify below:

Date Initials of nurse Transport Plan agreed and arrangements made to date and progress (if applicable) Responsible adult available to escort home if using own/public transport? Date Initials of nurse

Y N N/A Y N N/A

Have any ongoing nutritional care needs identified and communicated to carer/relevant agencies? Y N N/A Specify; Nutritional status, special dietary requirements, follow-up arrangements. Has the patient / carer been given information regarding any warning signs/complications to be aware of and who to contact? Y N N/A Date Initials of nurse

Do the patient / carer understand the core treatment they received? Y N N/A Healthcare / self care / advice and information given to patient and/ or carer Y N N/A state what type(s): Carer support referral postcard given? Y N N/A Date Initials of nurse

Medications ordered and sent to pharmacy Date Initials of nurse Delivered to ward Date Initials of nurse Dressings / catheter / equipment ordered Specify: Date Initials of nurse

Y N N/A

Patient’s home is suitable for them to return to? Patient has key / access to inside of their home? Patient has clothing and footwear to go home in that is appropriate for the weather conditions?

Y N N/A Y N N/A Y N N/A

If any issues highlighted from any of the information obtained during the admission or as part of the discharge plan, including if the patient has triggered RED or AMBER on any of the traffic lights: -

• Please describe plan and interventions required for effective and safe discharge including any conversations you have with the patient/carer on Discharge Plan Continuation sheet

• If a referral to Social Work, Enablement Team, or District Nurse are required, please complete the Social work/District Nurse Referral Form THB (MR)565

• For patients with a Learning Disability; please consider holding a pre-discharge multidisciplinary meeting for the more complex patients

17

Date and Time

Discharge Plan Continuation Sheet Initial

18

Date and Time

Discharge Plan Continuation Sheet Initial

19

Date and Time

Discharge Plan Continuation Sheet Initial

Day of Discharge Final Check

Equipment/dressings etc. given to patient /carer?

Venflon removed?

Discharge documentation completed and sent /given to patient?

Patient / carer given medication?

Patient /carer given any leaflets / cards associated with medications detailing side effects and

cautions?

Valuables returned to patient? Out Patient Appointment/s state…… ………………………. Initials of Nurse Date Time

Y N N/A

Y N N/A

Y N N/A

Y N N/A

Y N N/A

Y N N/A

20

Investigations/Tests Date Result/insert labels E.g. catheter label, urinalysis

label

21

Shift Assessment

MANDATORY RISK ASSESSMENTS & TREATMENT PLANS

PA

DO

SA

E L N E L N E L N E L N E L N

(N) NUTRITION

‘MUS’T’ 0 or Independent No risk identified

‘MUST’ 1 or requires assistance/encouragement/oral supplements

‘MUST’ 2 or more / dependant/NBM/Enteral/Parenteral nutrition/swallowing problems/ on food or weight chart

(PUP) PRESSURE ULCER PREVENTION No risk using PPURA or Waterlow, <10 and/or No ulcer

Waterlow >10 and at risk or Grade 1 or 2 pressure ulcer

Waterlow >10 at risk, and Grade 3 or 4 pressure ulcer and or cannot /will not reposition

(M) MANUAL HANDLING & MOBILITY Independent

No risk identified

Requires supervision or assistance walking aids/ additional equipment

Dependant New problem

(F) FALLS No history of falls

No risk identified

History of falls Risk factor identified/ New fall since admission

RECORD CARE REQUIRED AND GIVEN FOR ANY AMBER & RED RISKS

(A) AIRWAY/BREATHING No airway/breathing problem

No risk identified

Existing airway/breathing problem identified

New problem identified

(O) OBSERVATION & MONITORING SEWS 0 – 1

SEWS 2 – 3

SEWS 4 or more New risk/Nurse Concern

(E) ELIMINATION

Independent No risk identified

Requires supervision/assistance Problems with input/output or catheter / bowels/stoma

Dependent / incontinent of urine/faeces/new stoma/new bowel/bladder problem

(FB) FLUID BALANCE/HYDRATION Independent

No risk identified

Requires Fluid balance monitoring /assistance or encouragement to drink.

Active Fluid Management New problem identified

(P) PAIN (refer to PAINGO assessment) No pain or score 0 – 1

Pain score 2 – 3

Pain Score 3 continuous at rest

(W) WOUND/SKIN INTEGRITY

Skin healthy - No risk identified

Skin fragile/ dermatological condition/dry skin Clean surgical wound

Open wound/skin damage/excoriation, or extravasation of IV medication/ wound requiring active management

22

RECORD CARE REQUIRED AND GIVEN FOR ANY AMBER & RED RISKS

PA

DO

SA

E L N E L N E L N E L N E L N

(PH) PERSONAL HYGIENE Independent

Requires supervision/assistance &/or encouragement

Dependant

(OH) ORAL HYGIENE

Independent - brushes teeth/dentures by self

Requires assistance/observation to brush teeth/ dentures

Dependant/active assistance with oral care required / Oral trauma/ acute oral complaint

(I) INFECTION CONTROL No known risk (follow HAI)

Infection risk identified any Invasive Device PVC/CVC/PICC

Confirmed infection

(C) COMMUNICATION No Communication barriers identified

Existing communication barriers

New communication Barriers

(LD) LEARNING DISABILITY No learning disability

Learning disability identified (Contact Learning Disability Liaison Team)

(PS) PERSONAL SAFETY Not ambulant/ Ambulant but clinically stable

Mentally capable of making sound judgments Legible ID bracelet in place

Ambulant, but clinically unstable Current smoker/ Alcohol or Substance misuse/ History of wandering/ Concerns for patient safety/ Impaired judgment/Use of bedrails

(PC) PSYCHOLOGICAL CARE

No psychological care needs / challenging behavior identified

Patient has concerns/underlying condition. Requiring psychological/spiritual care input/ has some challenging behaviour that is managed

Patient experiencing intense emotions/ distress OR physical or self injurious behaviour/ aggressive towards others. Requiring immediate professional input

(S) SLEEP

No sleep problem identified

Altered sleep pattern/ difficulty sleeping/ insomnia

(CF) COGNITIVE FUNCTION ( Please follow clinical guideline: The management of delirium in adult and older in-patients (July 2011) appendix 2-4 for CAM assessment guideline)

No problems identified

Cognitive Impairment with controlled symptoms / mild confusion

Acute change in cognitive function, delirium or deteriorating dementia with significant symptoms Longstanding mental health condition e.g. depression, schizophrenia or psychosis (Contact dementia/ MH liaison team/ communicate with previous care setting if appropriate)

(ACN) ADDITIONAL CARE NEEDS

INITIALS OF NURSE