Self Care GG
What is:
Not Att MC
*There is a medical reason why it is going through a tube feed and not by mouth
A patient can roll to the Right with Partial A, however due to increased pain a patient needs two people to roll to the Left. This is the GG score you would put for Rolling L and R
What is:
Dependent
*score what they needed the most assist with
These two forms are required nursing admission forms that will flow to form browser once completed at admission
What is:
Adult Patient History
Adult Admission Assessment Rehab Form
This is when the "Nursing Discharge Form" should be filled out.
What is:
Day of Discharge
(Form must be timed before the patient leaves to be accurate)
unintentional change in position coming to rest on the ground, floor, or onto the next lower surface is the definition of this.
What is:
Definition of a Fall
A patient can get dressed by themself however, they only need assist putting on a TLSO. This is the GG score to use:
What is:
Partial Mod
A patient transfers out of bed to wheelchair. However, you manage their oxygen tubing as they maneuver to the wheelchair with their transfer (but do not touch the pt). This is the GG score to give for Transfers.
What is:
Supervision/Touch A
*you remained physically close to patient to manage equipment
This is when the depression screening will trigger during the patient's 3 day admission window
What is:
on day 2 (morning after they get here at 7 am
This is when the depression screening will trigger during the patient's 3 day discharge window
What is:
Day before a patient discharges at 7 am unless Case Manager has to manually change the discharge date
This needs to be filled out each time a patient falls at Van Matre
What is:
Post Fall Assessment
These are the three areas/steps included in toilet hygiene for GG scoring.
What is:
Pants/clothing management
Pericare/hygiene
Return pants/clothing management
These are the scores to use if the patient is using a urinal or bed pan when scoring TOILET TRANSFER..
What is:
Not Att MC or Patient Refuse
only in a rare instance should you use Not APP. That is when we will not expect a patient to do a toilet transfer after they leave VM
when marking GG Functional Scores in the adult admission assessment rehab form, this score should be used for items not yet attempted in the Nursing admission.
What is:
TBE
(do not use not applicable. This should only be used if they didn't do it prior to injury and we don't expect them to do it when they leave Van Matre)
Falls since admission and IV in 3 day discharge window are the required elements for what discharge form
Nursing Discharge Form
True or False:
in the narrative of the post fall assessment, it should be clearly stated where or what injury occurred
True
A patient needs TEDs for blood pressure management. This is the area of self care GG that it would be documented under (footwear, LB dressing, UB dressing)
What is:
Footwear
A patient requires a hoyer to move about the room and because of that they cannot complete a full stand. This is the score to give the item of sit to stand
Not Att MC
*A hoyer cannot put you in a standing position. you can however score sit<>Stand lifts based on assist needed.
In Adult Patient History Form (1 of required admission forms) this is the criteria to meet the question for prior surgery (did the patient have major surgery during the 100 days prior to admission?)
What is:
-The patient had surgery in the 100 days prior to admission
-The patient had to spend overnight in hospital after surgery
-The surgery carried some degree of risk to life
Skin tears, abrasions, bruises, lacerations, complaining of pain are all examples of what level of injury for a fall
What is:
Injury Except Major
*Major injury is bone fractures, joint dislocations, Closed head injuries
If a patient newly complains of pain after a fall (up to 24 hours) this form should be corrected/updated
What is:
Post Fall Assessment (Level of injury section)
What is:
Lower Body Dressing
A patient can roll to the Right with Partial A, however due to their WB status of NWB on Left Hip they cannot roll to the L. This is the GG score we would give the patient for Rolling L and R
What is:
Not Att MC
Medically due to precautions they could not roll one direction. The pt must roll both directions to get the score
In Adult Patient History Form (1 of required admission forms) this is the criteria for clicking "yes" for history of falls.
What is:
2 or more falls in the past year
any fall with injury in past year (complaining of pain or worse)
This is how you would fill out the Nursing Discharge Form for a patient that fell and had a skin tear to their arm.
What is:
Yes patient had a fall
No Injury: None
Injury Except Major: One
Major Injury: None
This is the 3 locations falls are to be noted/talked through. (or pieces of documentation)
What is:
Safety Huddle
Post Fall Assessment
RL6
for nursing (progress note)