A staple in the care of a patient is the patient care plan. With the conversion to electronic medical records, all disciplines who have contact with the patient “feed” into an electronic form that each discipline updates on a regular basis. Our department updates or verifies this form once a shift (www.floridahospital.com) generally near the end of the shift although new therapy orders are charted with start of therapy. I believe other disciplines follow the same schedule. All disciplines chart on the same electronic form.
The most important and effective control to ensure the different disciplines stay consistent with patient-centered care is communication. This communication must translate from verbal to written. Doctors tend to be the worst at communicating their plan for the patient while in the hospital. Well, those who see a doctor on even a semi-regular basis know that doctors don’t always communicate their plan even with the patient. This trouble with communication is universal. My own doctor doesn’t communicate with me well; I have to drag the information out of him. Let me say here that this is not every doctor. Some are really great at communicating their plan and will ask for staff input and modify their plan if warranted. That’s the doctor you want. I have seen doctors talk over a patient with the patient turning their head back and forth with their facial expression changing as the doctors discussed their illness. Finally, as they left the room, they said to the patient, “See you tomorrow.” The patient looked at me and asked, “What did I need to be here for – the doctor’s convenience?” Never be afraid to question your doctor or other healthcare provider. Write your questions down and do not worry about how “busy” or annoyed they may appear. It is your health and your life – you take control, not the doctor. But don’t be obnoxious or belligerent or a pain in the buns. Oh, now I’m off on a tangent.
Our facility also requires that patient care staff, primarily the nurse and therapist in ICU, go on patient rounds with the patient’s physician.
Reference:
Policy and Procedures, Department of Respiratory Care, Florida Hospital, www.floridahospital.com
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