NORTHALLERTON
HEALTH
S E R V 1 C E S
MENTAL HEALTH
MULTIDISCIPLINARY
COORDINATED CARE PLAN
Detoxification Regime
Patient's Name ______
Hospital Number ______DOB______
Named Consultant ______
Key Nurse ______
Sector Team ______
Abbreviations used in this document:
RMNRegistered Mental NurseTPRTemperature, Pulse & Respiration
SHOSenior House OfficerBPBlood Pressure
OTOccupational TherapistSWSocial Worker
S/BSeen byGPGeneral Practitioner
TTO'sTo Take Out (Drugs)CPNCommunity Psychiatric Nurse
NORTHALLERTON HEALTH SERVICES TRUST
COORDINATED CARE PROGRAMME
MENTAL HEALTH
INFORMATION SHEET FOR PATIENTS
This sheet has been produced in order to provide you with some additional information regarding your stay within the Mental Health unit at the Friarage Hospital.
We are currently looking at ways of making sure that the care we offer is:
EFFICIENT
THE RIGHT CARE FOR YOU
THE HIGHEST QUALITY
One way of achieving these objectives is by clearly agreeing and documenting patient care therefore, the doctors, nurses and therapy staff in the Mental Health Unit have met together to discuss and decide what tests and treatments need to be done whilst you are here, and when is the best time to do them.
This is then put onto paper and called a "Coordinated Care Plan" or a "Patient Focused Plan" because it lists all the really important events and the best time for them to happen.
The nurses will show you this documentation and answer any questions you may have. Your treatment and care continues to be kept in confidence at all times.
Of course, there may be very good reasons for some of these events not happening at the stated time, and the doctors and nurses will use their experience and professional judgement to decide the best care for you. When each event has happened they will sign by it, so that it is easy to see what care has been given and what still needs to be done.
The programme is still in its infancy, and although the care given to patients will be consistent, the paperwork for the staff will be different when they are using the "Coordianted Care Plan" system.
If you have any questions of comments about your plan of care the nursing staff will be happy to discuss it with you.
MULTIDISCIPLINARY PROTOCOL
DETOXIFICATION REGIME
SPACE FOR ID LABEL
NAMED CONSULTANT ......
SECTOR TEAM ......
Admission Date ......
Planned Discharge Date ......
DATE / ACTIVITY / STAFF / SIGNATUREDAY ONE
ARRIVAL ON WARD
Shown to bed area within 15 minutes / RMN / ......
Team SHO made aware of patients arrival / Medic / ......
Referral source checked / RMN / ......
Introduced to named nurse / RMN / ......
Orientation around ward/unit / RMN / ......
Smoking areas indicated / RMN / ......
Clerking in (joint) / )RMN / ......
)Medical / ......
Initial Nurse Assessment / RMN / ......
Physical Examination / Medical / ......
Alcometer reading / RMN / ......
Alcohol/Drug contract read and signed
by patient / RMN / ......
Obs level prescribed and explained / RMN / ......
Detox regime explained / Medical / ......
DATE / ACTIVITY / STAFF / SIGNATURE
Medication & Vitamins prescribed (if necessary / Medic / ......
Belongings checked / RMN / ......
Admission check list completed / RMN / ......
BP & TPR / RMN / ......
Care Plan formulated / RMN / ......
Visiting times / RMN / ......
OT. Referral / RMN / ......
Sleep monitored & recorded / RMN / ......
DAY TWO
Mental state assessed / RMN/Medical / ......
Self Care needs/ability assessed / RMN / ......
Medication reviewed / Medical / ......
1: 1 Primary nurse counselling/ relationship building / RMN
Diet monitored and recorded / RMN / ......
Bloods by day 2 / Medical
Physio as necessary / Physio
Monitor and record sleep / RMN / ......
DAY THREE
Self care needs reassessed / RMN / ......
Obs level reviewed (within 3 days) / Cons / ......
1: 1 Primary nurse counselling Alcohol Education / RMN
DATE / ACTIVITY / STAFF / SIGNATURE
OT assessment Day Hospital and Detox group / RMN
Medication reviewed / SHO / ......
Fluids/diet tolerated / RMN / ......
Monitor and record sleep / RMN / ......
DAY FOUR
Attend day hospital / RMN
1: 1 Primary nurse Alcohol Ed. Trigger factors / RMN
Anxiety management / RMN / ......
Diet monitored & recorded / RMN / ......
Monitor and record sleep / RMN / ......
DAY FIVE
1: 1 Primary nurse coping strategies / RMN / ......
Home Assessment S.W. / Social Worker / ......
Assess mental / physical state, review
medication / Medical / ......
Attendance to detox group / O.T. / ......
Monitor & record sleep / RMN / ......
DAY SIX
1: 1 Nursing staff plan discharge / RMN / ......
Monitor and record sleep / RMN / ......
DATE / ACTIVITY / STAFF / SIGNATURE
DAY SEVEN & EIGHT
MDT review to finalise discharge: liase medics, patient,
provide info ref special units and rehab if
necessary, CPN, S.W, Psychologist &
O.T, HARCAS, Dep Task Gp, Vine
Hse, AA. ALAnon / Key Nurse / ......
1: 1 Alcohol Education / RMN / ......
Transport / RMN / ......
Monitor and record sleep / RMN / ......
DAY NINE
1: 1 Nurse / RMN
Liase with patients family/identify any problems / RMN
DAY TEN
Inform G.P., SW, of any other agencies relevant / RMN/Medical / ......
Tasks to be completed by end of admission, but not on any specific day:
DATE / ACTIVITY / STAFF / SIGNATURE...... / S/B Consultant / Cons / ......
...... / Liaise with patient family
re:discharge/advice / RMN/Medical / ......
...... / TTO's + discharge letter / Medical / ......
...... / OP appointments / Medical / ......
...... / Inform GP, SW and other agencies / Medical/RMN / ......
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VARIANCE TRACKING SHEET
DATE / DAY NO. / TIME / VARIANCE AND REASON FOR IT / VARIANCE CODE / +/- / ACTION TAKEN / SIGNATUREVARIANCE CODES
INPATIENT CONDITIONSTAFFSYSTEM
1 HIGH BP16 PHYSICIAN DECISION26 EQUIPMENT AVAILABILITY
2 LOW BP17 NURSE DECISION27 DEPARTMENT CLOSED (BH or WIE)
3 COMPLICATING MEDICAL CONDITION (SPECIFY)18 PARAMEDICAL DECISION28 SYSTEM OTHER
4 NEUROLOGICAL DETERIORATION19 PHYSICIAN AVAILABILITY
5 BALANCE20 NURSE AVAILABILITY
6 PAIN21 PHYSIO AVAILABILITYFAMILY / CARERS
7 PERCEPTION22 OT AVAILABILITY
8 SHOULDER PAIN23 SPEECH THERAPIST AVAILABILITY 29 FAMILY DECISION
9 SWALLOW PROBLEMS24 SOCIAL WORKER AVAILABILITY30 FAMILY AVAILABILITY
10 PATIENT UNCO OPERATIVE25 STAFF OTHER31 FAMILY NOT KEEN
11 UNCONSCIOUS
12 PRESSURE SORE
13 CHEST INFECTION
14 OTHER
15 PATIENT ALREADY WASHED & DRESSED
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