Chart Audit
These two phrases should be included in every intake note.
What is "Orientation to the unit" and "Patient's Rights Packet"?
This tool shows that we are fully engaged with the patient and includes behaviors such as reflective statements and direct eye contact.
What is active listening?
If you fall out of compliance from Relias, this is the result.
What is being pulled off the schedule?
When approached by a patient and asked about medications a Peer should do this.
What is go into the bubble and advocate to the nurse face to face?
This annual requirement is due by November 1st.
What is a Flu-shot?
This should be included, as much as possible, in every note.
What are direct patient quotes?
This is where we advocate for the patient and tell the story in their own words.
What is documentation?
This is where we should be engaging with the patients especially for wellness checks.
What is at their chairs or a side room?
(Meeting them where they are at)
When a patient expresses they want for further treatment, a Peer should do this.
What is staff with the Case Manager to find appropriate placement?
When entering and exiting the unit, staff should do this.
What is:
Shut the door behind them
Take off gloves
Communicate to the Supervisor
This tool should be offered to every patient prior to discharge for use in times of a crisis.
What is a Safety Plan?
You should do this when a patient's behavior changes abruptly and they begin pacing the unit.
What is engage with them?
This should be included in every patient's chart daily.
What is a peer note?
When a patient notifies you that they are having issues with another patient, you should do this.
What is collaborate with the BHS staff on the unit?
We should be doing this as soon as possible after witnessing significant events including: physical aggression, injury, medical events, or seclusions.
What is an Incident Report?
These should be incorporated in some groups to add diversity and the ability to reflect on.
What are worksheets/handouts that the patients get to keep?
This model can be used effectively to de-escalate or redirect a situation with a patient that is agitated.
What is the CALMS model?
Within the first 2 hours after admission, the patient has the right to receive this.
What is a phone call?
A patient with a history of substance abuse issues is discharging, we should staff with the provider to make sure they leave with this.
What is Narcan?
This is something all Peer Supports have in common and the reason we chose this path.
What is Lived Experience?
This should be added to our documentation to show follow through for resources offered or completed Safety Plans.
What is "Provided the patient a copy"?
This is a set of principles and techniques to help an individual change unhealthy behaviors and develop healthier coping mechanisms.
What is Motivational Interviewing?
During periods of high acuity or prolonged down time, RSS staff should do this.
What is put together an impromptu group?
This is when you advocate or collaborate with the other team members regarding a patient's wellbeing.
What is interdisciplinary/multidiscipline collaboration?
The understanding of the widespread impact of trauma and the need for sensitive support is know as this.
What is "Trauma Informed Care"?