CHANGE OF CONDITION

SBAR

The Focus to Resident Care, Documentation &

Audits

Regulatory Requirements

• Change of condition documentation is required by:– Federal Regulation– State Regulation– Standards of Practice for communication with the

physician and good quality of care in the facility

• SBAR – Clinical Care Paths and the SBAR system– Anytime there is a change in condition, the urgency

will dictate how quick2

Change of Condition

• Title XXII 72311(a)(2)

• Nursing service shall notify the physician of– (B) Any sudden and or marked change in signs,

symptoms or behavior exhibited by the patient– (C) Any unusual occurrence involving a patient– (D) Change in weight of 5 lbs. (or 5%) of more

in 30 days*

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Change of Condition -2

• Title XXII 72311(a)(2)– (E) Any untoward response to a medication or

treatment– (F) Any error in administration of a medication

or treatment– (G) All attempts to notify physicians shall be

noted in the patients record including the time, method of communication and the name of the person acknowledging contact

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SBAR

• When to call the MD– Vital signs– Lab reports– Change in Condition

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What Is SBAR About?

• Representative the resident and the facility in a highly clinical fashion

• This is the reference to the evaluation/observation if the resident and the findings on that review.

• Knowing the code status and presenting that to the physician as applicable

• Providing the background status re: the resident

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What Is SBAR About? -2

• Gives the physician an immediate past Hx, admission diagnosis

• Describes recent lab work any key medications – focus on medications that are related to the condition or may impact

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Change of Condition -3

• F-157 §483.10(b) The facility must immediately inform the resident; consult with the resident's physician; and, if known, notify the resident’s legal representative or an interested family member when there is…

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Change of Condition -4

• Notify when there is:– An accident resulting in injury or potential injury

requiring MD intervention– A significant change in physical, mental or

psychosocial status (i.e. deterioration in health)– A need to alter treatment

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Change of Condition -5

• The SBAR – Change of Condition process will be used for all C of C

• Change of Condition form to be used (H.O. #2.2)

• If the form does not accommodate the change of condition, document in the Nurse Progress Notes and use the same process to describe the condition change, i.e., Situation/Presenting Problem, Vital Signs

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Change of Condition -6

• Evaluate/observe the condition and document the findings applicable to the condition, i.e., Resp., UTI, falls, etc. and follow up with the physician; also provide all the required clinical observations and vital signs

• Use SBAR Process

• We will review the form/format a little later

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Change of Condition Monitor

• An integral part of– Daily Stand up will review residents w/ C of C

via the C of C Monitor

• Ensures prompt follow up and complete documentation for any change of condition including those identified by resident or family complaints or concerns

• Identifies trends or problems for prompt attention and possible follow up by the CQI Committee and Risk Management Program

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SBAR

• This is the reference to the evaluation/observation if the resident and the findings on that review

• What is the Situation or Presenting Problem

• What are the Vital Signs and are these within normal limits? Be prepared to discuss these with the physician in ALL CASES when the physician is called

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What Is SBAR About For Asm’t?

• What the observations point to on examining the resident?

• Provide key information from the areas observed/examined

• Some body systems may have no abnormal signals/symptoms

• Determine the area that is presenting the primary problem for the resident; do not dismiss other body systems

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SBAR -2

• Observation/evaluate and identify those areas that need assessment for the presenting problem, i.e., Mental Status – this area may be relevant to any number of conditions i.e., UTI, Falls, etc.

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SBAR -3

• Consider if the condition is a:– Cardiovascular issue– Respiratory– Gastrointestinal– Genitourinary– Possible Infection-Generalized– Skin Condition– Fall– Unplanned weight change….etc.

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SBAR -4

• While there may be other conditions not on C of C form, then use the Nurse Notes and not the Change of Condition Form

• If resident is placed on Oral Antibiotics, also use SNF form, Physician Oral Antibiotic Orders, in addition to the Change of Condition format as you are doing now – aside from your Nurses Notes

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SBAR Change of Condition – Fitting into the Big Picture

Quality Care & Review System

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Acute Mental Status Care Path

• When making an assessment of the Mental Status of the resident, consider that may affect many of the changes of conditions also for other areas besides Mental Status

• Refer to the Book – Guide to Nurses

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Acute Mental Status

• Let’s review the Care Path (H.O. #2.3) and the clinical decisions that are important for evaluation/observation and notification to the physician when it comes to Acute Mental Status and/or just the Mental Status and other conditions and how it may affect the other changes in condition

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Congestive Heart Failure

• Let’s review the Care Path (H.O. #2.3) for symptoms and the clinical decisions that are important for evaluation/observation and notification of the physician.

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Change of Condition Form

• Let’s review the form (H.O. #2.2) you will complete – Check out the Cardiovascular and the Respiratory and the condition you are observing/evaluating

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Dehydration

• Let’s review the Care Path (H.O. #2.4) for symptoms and the clinical decisions that are important for evaluation/observation and notification to the physician. Note this gives you a clue of other areas you should evaluate/observe- i.e. Mental Status, Functional Status, Respiratory, GI and Skin

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Change Of Condition Form

• Let’s review the form (H.O. #2.2) you will complete. Check out the Dehydration, mental status, respiratory, gastrointestinal and skin. What are your findings on observation/examination? Document those findings before calling the physician.

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Fever

• Review of the Care Path (H.O. #2.4) for undetermined origin

• Evaluate the Mental Status, Functional Status, Respiratory, Gastrointestinal, Skin

• Is there a change in ability to eat or drink?

• New cough, lung sound changes, incontinence, pain, new skin condition

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Change Of Condition Form

• Let’s review the form (H.O. #2.2); note there is the place to document Fever and determine if it is above the normal. Dr. notification of the fever alone is not enough. Evaluate the other systems to determine if there are symptoms for any of these areas. Also, make added notes in the nurses notes if there is not enough space here or you have added information

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Respiratory Infection

• Review of the Care Path (H.O. #2.5) focuses on the following:– Vital signs and the normal vs. abnormal.– Consider any recent lab. X-rays– Review results of the recent labs.-x-rays and the

positive/negative findings– If Antibiotic. Remember to complete the

Antibiotic sheet

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Urinary Tract Infection

• Review the Care Path (H.O. #2.5)

• Consider the Vital Signs; > temp. Glucose

• Lab Testing and any urinalysis maybe already completed and the findings,

• Look at recent blood counts, persistent nausea and vomiting, unstable VS

• Dysuria, alone, Fever, frequency, urgency

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SBAR C of C Form

• Review Change of Condition Form (H.O. #2.2)– Consider the Vital Signs and abnormal results– Mental Status– GI/Hydration– GU– Skin– Falls, if there was also a fall.

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SBAR C of C Form -2

• Review Change of Condition Form

• General Instructions– On change in Resident’s condition, the licensed

nurse evaluates the situation, identifies presenting problems, gathers information on all applicable systems and reports key observational findings to physician.

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SBAR C of C Form -3

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SBAR C of C Form –4

• BACKGROUND AND REVIEW OF VITAL SIGNS AND FINDINGS

• Document Review of Recent labs – consider the SBAR for the various conditions and the abnormal findings

• Identify any new medications recently ordered and has the change occurred since then???

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SBAR C of C Form -5

• List any allergies as those need to be known to tell the Physician in case there are med. Orders

• Identify the system review.

• Physician’s Notification and response

• Resident and Family, Resp. Rep. notified

• Add additional comments, date and sign

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SBAR C of C Form -6

• If need additional space use the Nurses Notes, Enter, Date, Time

• At any time if a nurses note is not complete before you start the C of C form, draw a diagonal line through the page. Write See C of C.

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Question…

• Initiate SBAR Form

• Document on SBAR

• If a page on Nursing Notes was partially filled then draw a diagonal line, date and sign

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Make It Happen!

It’s up to

you!36