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The Discovery Process

blogI like to read courtroom dramas in my spare time.  I especially like the ones where the nobody lawyer gets a case that he cannot possibly win but his client is innocent, and then against all odds, like Rocky of the courtroom, the small town lawyer wins the case.

These books are not completely without educational merit.  I have learned all about the discovery process, for instance.  Get this – when one side asks the other for evidence, they have to hand it over – just like ADRs.  Obviously, there are prosecutors all over these dime store paperbacks that do not want to show their hand to the defendant but the law is the law, right?

Here’s the educational piece.  What happens is that when one side is compelled to turn over a document to the other side and they really don’t want them to see it, they put it in a box with thousands of other documents.

Some of you already knew that, didn’t you?  I know that because I read your documentation.

Here’s an actual set of goals from an otherwise excellent chart.  Note there is nothing horrible about these goals but work with me, folks.

    1. The patient will have no hospitalizations during the episode.
    2. Patient will have absence or control of pain as evidenced by optimal mobility and activity necessary for functioning and performing ADLs by the end of the episode.
    3. Patient skin integrity will remain intact during this episode.
    4. Patient will be free from signs and symptoms of respiratory distress during the episode.
    5. The Patient/Caregiver will verbalize and demonstrate edema-relieving measures by end of episode
    6. Patient will maintain low na+ diet compliance during the episode.
    7. Patient will have increased mobility, self care, endurance, ROM and decreased pain by the end of the episode.
    8. The patient will be free from falls during the episode.
    9. The patient will be free from injury during the episode.
    10. Patient will remain free of adverse medication reactions during the episode.
    11. The Patient/Caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects by end of episode.

Now, take the painful journey with me starting at the first goal.  Whether or not the patient is hospitalized is not a stand alone actionable goal.  Sure, you could lock the patient in the closet but the real goal isn’t to keep them out of the hospital.  That’s a lie Medicare told us to save  money.  The real goal is to keep them from requiring inpatient care.  You accomplish that outcome by creating patient specific goals relative to the identified risks of the patient and following through with interventions crafted to meet those goals.  (Obviously, I have been doing too much Joint Commission work lately.  What I meant to say is you keep the patient out of the hospital by taking care of the problems that might land him inpatient somewhere.)

Moving right along, without violating any HIPAA regs, let me just state that the patient had no pain upon admission, no pain medication ordered except prn Advil which was rarely taken and no reason to think she would get pain.  More importantly, it would be unreasonable to think that lowering her pain level from zero would in any way, shape or form lead to optimal mobility and activity for performance of anything.

The third goal addresses skin integrity.  Note that the nurse wants the patient’s skin integrity to remain intact….  How does that work in a patient who was admitted for cellulitis?

The respiratory distress goal is admirable.  Everyone should remain free of respiratory distress.  This patient is free and clear of respiratory illnesses so it appears as though the goal was just taking up space.   Its kind of like writing the patients heart will beat throughout the episode.

The patient/Caregiver (which caregiver, folks?  The patient lives in in an ALF) verbalizes and demonstrates edema relieving measures.  Wow!   Does that mean the patient will put their feet up while they watch tv?  Does it matter what they verbalize?  I am quite certain that people will say almost anything.  Maybe a better goal would be that the patient had 1+ or less edema throughout the epsiode.  I think it’s kind of lofty to assume the patient with cellulitis to their lower legs will have no edema.

The pt will not eat a lot of salt.  Really?  That’s a goal for a patient who lives in an ALF where her food is prepared by the facility?  Should dietary sodium intake be the focus of care for a patient who is 90 years old and takes a single low dose of blood pressure meds and has no recent exacerbations?

The 7th goal is quite impressive in it’s verbiage but its useless.  How do you reduce zero pain?  I think the 90 year old patent is doing damn good to be in an assisted living facility ambulating with a walker and receiving only intermittent assistance from home health for her cellulitis.

Check out goals numbers 8 and 9.  The patient will not fall and the patient will not be injured.  Unless there is a serious violent crime problem at the ALF, it occurs to me that it might be more efficient to write:  The patient will be free from injuries related to accidents or falls (or gunshot and knife wounds) this episode.  And while a zero tolerance for injuries is an admirable goal, it is important to remember that it is a goal.  Goals are not like wishes.   We must direct care towards them.  How about a little therapy, folks?

The last two goals are about drugs.  The drugs in question are bactrim, thyroid medication, amlodopine and an NSAID for occasional pain.  I think that’s kind of impresssive for a 90 year old.  And while medications are extremely important, I happen to know the ALF has a med program and even without, I think one med goal would be sufficient.

What’s missing?  You didn’t see it did you.  It’s like looking through a box of documents produced as part of discovery.

Where is a goal related to the patient’s cellulitis?

Important Note:

Many of you received my email regarding Southeast Louisiana Home Health and South Louisiana Home Health, Inc.  I mistakenly wrote in a previous post – now removed, that Southeast Louisiana Home Health had a little fraud problem.  I was wrong.  It was the owners of South Louisiana Home Health, Inc. that were indicted for fraud.   The Department of Justice issued this press release where it is clear that the Ages, owners of South Louisiana Home Health, Inc. were the subject of the investigation.  I regret any confusion.

4 Comments Post a comment
  1. Shari Norris LVN, HCS-D #

    Not to name names but these are goals from Kinnser software, we use Kinnser at two of our agencies. We must look at goals a lot harder in the future.

    June 14, 2013

    • Yikes, Shari. I am probably going to open a whole new can of worms but these goals were from a different system.

      Most software systems have canned goals. The efforts that are taken in good faith by vendors to assist the nurses are being used as an alternative to individualized care planning. I would like to blame the software vendors but before computers, there were paper forms and the first goal on about half of the patients in the country related to falls because it was the first check box on the form.

      It doesn’t take much and unlike some things, such as the face to face, goals can improve patient care by giving direction to alternate caregivers. Nobody believes that anything will happen to them. Things do happen and nurses will have to go in blind to visit a patient. There is a direct correlation between the quality of information and the quality of care. Ideally, goals reflect the acuity and severity of the patient condition on admission so care can be prioritized.

      June 14, 2013

  2. I applaud you. I hate the canned goals and I usually add or subtract my own ideas, which usually you can do. The goals are supposed to be individualized to the patient, not quick and easy for the nurse. This is my beef about our computer systems. We still get dinged for lack of individualization!!

    June 14, 2013

  3. I hate canned anything. Orders will be next on my list!

    On the other hand, a good set of tools used properly go a long way to ensuring that nothing is overlooked. The nurse in the field sees the goal and views it as a yes/no question. It feels to the nurse that if the box is not checked, he or she is clearly indicating that it doesn’t matter if the patient can breath or if their skin remains intact.

    Whether it is a paper assessment or computerized, the nurse should be ready for it. Remember, the primary goal for the patient is that they will not die or circle the drain. To facilitate that, what is the greatest threat? To be realistic, what are the top three goals that if accomplished may keep the patient above ground little longer. When the nurse arrives at the check box for falls, does it really apply to the unstated, tasteless goal of refusing to let the patient die or circle the drain?

    Nobody is good enough to accomplish ten or more goals in a conservatively scheduled patient. Arm your nurses well.

    June 14, 2013

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