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Documentation & Communication

Documentation & Communication. The Challenge:. Research demonstrates that clear communication & documentation for mobility planning enhances function for our seniors during their stay in hospital

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Documentation & Communication

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  1. Documentation & Communication

  2. The Challenge: • Research demonstrates that clear communication & documentation for mobility planning enhances function for our seniors during their stay in hospital • Unclear communication & documentation leads to ineffective use of time trying to determine exactly what our patients are able to do in terms of how they move and how this changes on a daily basis for most

  3. The Solution: Clear Documentation & Communication: • Baseline function: How did my patient move before admission? (pre-admit functional status) • Record the following in the chart: • Mobility level on a daily basis (assessment) • Mobility activities (interventions) • Frequency • Duration • Example: • For a patient who can pivot to a chair: up to chair x2 for 30 minutes, ROM exercises done x3, dangle edge of bed 10 minutes.

  4. Establishing a Mobility Care Plan: • Establish baseline functional status and plan accordingly • Out of bed daily for all patients • Aim to have patients mobilize at least 3x day • Progressive mobilization that is optimized daily: • Every day, do a little more… • Ensure that mobility activities are recorded daily: • “ If it’s not documented, it didn’t happen”

  5. Communication: Key points for success • Integrate discussions about mobility into rounds • Communicate how your patient is mobilizing at shift report • Encourage clear medical orders that are action oriented (out of bed vs. AAT) • Use patient/family boards to display mobility to engage patients and their families • Use an inter-professional approach to creating & delivering mobility care plans

  6. A Final Note:Where do I find Information about Mobility? • In the chart: • Medical Doctor progress notes • Occupational and physiotherapy notes • Consult section of chart • Nursing Notes • Other places: • Patient information boards • Kardex • Care pathways if applicable • Communication boards for rounds

  7. Acknowledgements • <Your Hospital Name> is a member of the MOVE Collaboration, which is supported by the <insert funder’s name> • The materials presented here are adapted from the MOVE iT initiative supported by the AFP Innovation Fund, Ontario Medical Association and Ministry of Health & Long-term Care

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