Protect Your Practice – Helpful tips

1. Protect Your Practice – Helpful tips Monica Staley – Patient Representative 519-254-5577 Ext. 52317 Monica_Staley@wrh.on.ca

2. REVIEW THE IMPORTANCE OF: * DOCUMENTATION • What / Why / How * COMMUNICATION * PRIVACY * CONFIDENTIALITY OBJECTIVES

3. Scenario Mrs. S., a 45-year-old woman, is currently an in-patient receiving chemotherapy for the treatment of a malignancy. She consented to transfusion with blood products as part of her treatment and has thus far received several units of blood products. West Nile Virus (WNV) nucleic acid testing of donated blood commenced to prevent transmission of WNV through the blood supply. Positive donor testing leads to a recall of the donor’s products. Unfortunately, only three of eight blood products could be recalled from a positive donor. The other five units were transfused to Mrs. S.   Although Mrs. S. remains immunosuppressed from chemotherapy, she is currently clinically stable and well. Should it be disclosed to Mrs. S. that she received blood products that the donor tested positive for WNV? If so, when? If so, how? If so, by whom? WHAT WOULD YOU DO??

4. REFLECTS the client’s perspective • IDENTIFIES the caregiver • PROMOTES continuity of care by allowing other partners in care to access the information WHY DOCUMENT?

5. DEMONSTRATES the nurse’s commitment to providing SAFE, EFFECTIVE and ETHICAL care by showing ACCOUNTABILITY for professional practice and the care the client receives and TRANFERRING KNOWLEDGE about the client’s health history WHY DOCUMENT?

6. COMMUNICATES to all healthcare providers : • The ‘plan of care’ • The ‘assessment’ • The ‘interventions’ necessary based on the client’s history; and • The ‘effectiveness’ of those interventions • Is an INTEGRAL component on interprofessional documentation within the clinical record WHY DOCUMENT?

7. DEMONSTRATES that nurse has applied within the therapeutic nurse-client relationship the nursing KNOWLEDGE, SKILL and JUDGMENT required by professional standards regulations WHY DOCUMENT?

8. DEMONSTRATES the nurse’s commitment to providing SAFE, EFFECTIVE and ETHICAL care by showing ACCOUNTABILITY for professional practice and the care the client receives and TRANFERRING KNOWLEDGE about the client’s health history WHY DOCUMENT?

9. Documentation should provide a clear picture of: • The needs/goals of the client or group • The nurse’s actions based on the needs assessment • The outcomes and evaluation of those actions WHAT TO DOCUMENT?

10. DATA from documentation • Can be used to evaluate professional practice as part of quality improvement processes • Can be used to determine the care and services required or provided WHAT TO DOCUMENT?

11. NOT DOCUMENTED = NOT DONE!!!

12. INDICATORS ON DOCUMENTATION 3 STANDARD STATMENTS

13. Nurses ensure that documentation presents an accurate, clear and comprehensive picture of the client’s needs, the nurse’s interventions and the client’s outcomes 1. COMMUNICATION

14. Nurses are accountable for ensuring their documentation of client care is accurate, timely and complete 2. ACCOUNTABILITY

15. Nurses safeguard client health information by maintaining confidentiality and acting in accordance with information retention and destruction processes and procedures that are consistent with the standards and legislation. 3. SECURITY

16. CLEAR, CONCISE, COMPREHENSIVE” • REFLECTS PRIORITY PROBLEM” • PATIENT FOCUSED – what happened; what was done; who was told” • FOLLOW UP CARE” REMEMBER….

17. CAPTURES essential communication that has occurred within the interprofessional team. PURPOSE OF COMMUNICATION

18. Nursing documentation communicates • Assessment • planning • implementation • evaluation • client’s response to the care IT SHOULD INCLUDE…

19. COMMUNICATE the client’s PREFERENCES and EXPRESSED NEEDS. • INCLUDE CLIENT”S PERCEPTION of the care provided • SHOW CARE and CONCERN while communicating with client REMEMBER…

20. SUBJECTIVE DATA • Statements and feedback from client, in quotations • “I feel a stabbing pain in my stomach” • OBJECTIVE DATA • Observed or measured facts • Client was distressed. Temperature 39oC. DOCUMENTS COMMUNICATE TWO TYPES OF DATA…

21. INCLUDE IDENTIFIABLESIGNATURE and DESIGNATON (RN, RPN,NP) • KEEP PERMANENT records REMEMBER…

22. What is PATIENT-CENTRED CARE? • EMPATHY • WALK-IN PATIENT’S SHOES • ADVOCATING for the rights of VULNERABLE PERSONS • KNOW YOUR HIERARCHY TO ESCALATE & COMMUNICATE!! • The law ASSUMES that people have CAPACITY • CONSENT & CAPACITY • CAPACITY ASSESSOR COMMUNICATION

23. Must have prior consent to treatment, and consent must be informed and voluntary; Common law; now largely codified in Health Care Consent Act (HCCA); Person must have capacity to consent, i.e. able to (i) understand relevant info. & (ii) appreciate reasonably foreseeable consequences of deciding or not (s.4); Emergency exception (s.25) Consent and the Health Care Consent Act

24. Health care provider proposing trt. decides re capacity (in first instance) (s.10); Presumption of capacity (s.4 (2); Capacity can be trt-dependent and come & go over time (s.15); If patient is incapable, then substitute decision maker (SDM) consents to or refuses treatment. Capacity

25. Power of attorney (POA) for personal care (made by person concerned; low % of population have one); Who can make (min. age; test for capacity); Re health care: POA can say who decides, what to decide, or both; Also, guardianship (court order). Substitute Decisions Act

26. S.20: Who decides for another: lists SDMs in order of priority – appted by ct, person (POA) or Consent & Capacity Brd (CCB), then descending degree of relation; last resort = Public Guardian & Trustee (PGT); S.21: How to decide for another: (i) follow prior capable wishes if apply & person was at least 16; (ii) if none, SDM to act in best interests; S.5: Wishes: can be expressed in any form. Substitute Decision-Making in the HCCA: Guidance Principles

27. SDM shall consider: Prior capable values and beliefs; Incapable person’s wishes; Treatment factors: Is the trt likely to Improve condition or well-being; Prevent deterioration; Reduce extent or rate of deterioration; + Effect of non-trt on person; Weigh benefit & risk of harm from trt; Least restrictive or intrusive trt for this benefit? Determining Best Interests HCCA s.21(2)

28. Person concerned can challenge practitioner’s finding of incapacity (s.32); Health care practitioner can challenge SDM’s compliance with s.21 (decision making principles) (s.37); SDM or HCP can apply to CCB to clarify wish or to disregard it if likely result much improved from when made (ss. 35, 36); Further review by court. Consent & Capacity Board

29. PHIPA – Personal Care Information Protection Act • Circle of Care – Are you in it? • Telephone – Who can you disclose information to? • Fax Communication – Are you permitted to send it? • Social Networking • Electronic Audits • Know where you are when you speak PRIVACY & CONFIDENTIALITY