No Documentation of Heart Failure Discharge Instructions

1
No Documentation of Heart Failure Discharge
Instructions
A. Complete discharge instructions provided but
not documented
B. Complete discharge instructions not provided
2
A. Complete discharge instructions provided but
not documented
Defined responsibility process failure
No defined responsibility process failure
and
and
A2. No designated staff person responsible for
documentation
Process check fails
A1. Designated individual (position) responsible
for documentation
Process check fails
A1.2. Discharge form not adopted by facility
A1.1. Discharge form adopted by facility
A1.2.1. Doesnt know expectation
A1.2.2. Doesnt know how to document instructions
A1.2.3. Lapse in documentation
A1.2.4. Decides not to document ?
A1.1.1. Doesnt know expectation
A1.1.5. Decides not to document ?
A1.1.2. Doesnt know how to complete form
A1.1.3. Error in form completion/documentation
A1.1.4. Decides not to use form (and errs in
documentation)
A1.1.4.1 Form not readily available
A1.1.4.2 Form inconvenient
A1.1.3.1 No form available (document from memory)
A1.1.3.2 Lapse in form completion
3
A2. No designated staff person responsible for
documentation
A2.1. Individual providing instructions thinks
(mistakenly) that someone else will document
A2.2. Individual providing instructions doesnt
know requirements for complete documentation
A2.3 Individual providing instructions forgets to
completely document
A2.4 Individual providing instructions decides
not to document
4
B. Complete discharge instructions not provided
B1. No instructions provided
B2. Partial instructions provided
B1.1 Patient not identified as HF
B1.2 Patient identified as HF
B1.2. No intention to provide instructions?
B1.2.2. Failure with responsible individual
designated
B1.2.1. Failure with no designated responsible
individual
and
and
B1.2.2.1. No provider instructs
B1.2.1.2. Patient/family prompt failure ?
B1.2.2.2. Patient/family prompt failure ?
B1.2.1.1. No provider instructs
and
and
B1.2.2.1.2. No prompt from other staff or process
B1.2.2.1.1. Designated individual does not
instruct
B1.2.1.1.1. Physician does not instruct
B1.2.1.1.2. Nurse does not instruct
B1.2.1.1.3. Discharge planner does not instruct
5
B1.2.2.1.1. Designated individual does not
instruct
B1.2.2.1.1.4. Availability failure
B1.2.2.1.1.1. Doesnt know they are supposed to
instruct
B1.2.2.1.1.2. Forgets
B1.2.2.1.1.3. Decides not to instruct
and
B1.2.2.1.1.4.2. No back-up/crossover
B1.2.2.1.1.4.1. Individual not available
6
B2. Partial instructions provided
and
B2.1. Instruction failure
Process check fails
B2.1.1. Instructor doesnt know all elements to
be covered
B2.1.2. Instructor forgets element(s)
B2.1.3. Instructor decides to omit element(s)