Standards of Care - Sample

__________________ Animal Hospital

Standards of patient care:

Effective immediately, specific healthcare standards of care must be initiated at ___________ Animal Hospital (__AH) by Dr. __________ and any other part-time or relief doctors:

 For the continuity of care and staff utilization, there can be only one version of the following protocols in the __AH:

 Canine vaccines

 Puppy programs

 Eligibility for skip-year vaccine programs

 Annual life cycle consultation requirement.

 Feline vaccines:

 Kitten programs

 Eligibility for skip-year vaccine programs

 Annual life cycle consultation requirement.

 Genetic/congenital predispositions

 Preferred web site

 Client handout

 Annual life cycle consultation requirement.

 Parasite prevention and control

 Feline programs

 Canine programs

 "Traveling With Your Pet" programs

 Annual life cycle consultation requirement

 Medical records

 Client "concern" starts each entry.

 All consultation records will be S-O-A-P or H-E-A-P

 Assessment(s) must address "client's concern" first

 Tell clients clearly what is needed

 Document all "needs" with a box ([ ])

 Client's response is recorded in the box: W = waiver, D = deferral, A = appointment, X = do it!, + = positive, - = negative

 Anything that is not resolved by the end of the consultation/visit is entered on the master problem list and followed by our nursing staff until resolution

 Patient care

 AAHA Standards are minimum requirement

 Physical exams will list all twelve systems as normal or abnormal

 Sequential weights will have body condition scores (BCS)

 Animals with teeth with have dental grades, zero plus four levels

 Hospitalization will be charged by care levels

 Increased OPNT surveillance of deferred or symptomatic care

 Blood chemistry screening

 Minimum mandatory with anesthesia

 CBC with chemistry

 Sequential laboratory surveillance.

 Pain management programs

 Pre-emptive scoring

 Inpatient scoring

 Surgical requirements

 Go-home protocols.

 Any animal entering ___AH will have the client concern documented as the first medical record entry, whether it be electronic or progress note paper. Each client concern will show an assessment, reflecting what the client was told about what was being treated.

 If a doctor orders any wellness screening (laboratory, imaging, etc.), the assessment of the testing results will be shown on the progress notes. Every consultation will have a S-O-A-P or H-E-A-P of the episode, and each S-O-A-P or H-E-A-P will reflect a twelve-system PE. Normal or abnormal will be recorded, and abnormal explained, including a pain assessment score, sequential weight, with a body score, and dental grade (0, 1+,2+, 3+, or 4+), whether it be electronic or progress note paper.

 Each provider will start to use the word "need" instead of "recommendation". When a "need [ ])" is stated, the room will fall silent until the client talks. The client response to each "need ([ ])" will be recorded as: W = waiver, D = defer, A = appointment, or X = do it. If the "need ([ ])" silence must be broken by any ___AH staff member/doctor, the statement must be similar to, "Is this the level of care you want for (pet's name) today?"

 All diagnostic screening (results) will be formally assessed on the progress notes. Sequential testing will be scheduled when any value/assessment is atypical.

 Informed consent means explaining why there "must be" laboratory screening before anesthesia; why there "must be" aggressive pain control before, during, and after surgery; why there "must be" laboratory screening before anesthesia; which type of reversible anesthetic program is being used; and why the procedure is needed and what prognosis is expected. Ensure the clients understand before they are requested to sign the hospitalization consent form.

 Inpatient admissions will be overtly entered into the progress notes, with an anesthetic risk assessment, levels one through five, and pre-emptive pain management program prescribed, appropriate to the expected outcome of the case.

 Inpatient care will be recorded on the white board for the treatment. New format may be needed to include the new scoring programs. And while anyone can write on the white board(s), only the senior IPNT is allowed to erase the white board(s). Erasure by the senior IPNT will indicate the services/products have been entered into the medical record, whether it be electronic or progress note paper, plus the invoice.

 All "needs ([ ])" will be recorded in the medical record, and all healthcare delivery will be recorded as it is done, whether it be electronic or progress note paper. Dictation by the doctor and writing by the nursing staff is acceptable and preferred for surgery cases, so that during closure, the records are written by the attending surgery nurse, and ready to be signed by the time the doctor "pops gloves". No shift ends if there is any workload pending documentation. All healthcare documentation is completed before any shift ends, doctor or nurse. There is no excuse for loss of continuity of care.

 Discharge planning is discussed by the attending doctor with the client by phone before the discharge is scheduled. All discharges are scheduled with the attending IPNT after the doctor has discussed the inpatient procedures and outcomes with the steward of that animal. During the telephone discussion, the doctor completes the patient-specific discharge instructions for use by the attending nurse later that day. The discharge planning always plans the next expectation for contact by the practice.

 The expected number of visits per year per pet will become part of the ___AH narrative for each client contact, and the next contact or return will be established as an expectation.

 Any problem not resolved during the ___AH episode must be entered on the master problem list, and assigned to an attending nurse to follow up by telephone until the condition/concern is resolved, which includes atypical laboratory values, unresolved dental grades, nutritional body scores, etc.

 No animal will be allowed to depart ___AH without being one of the three Rs (recall: phone them, recheck: schedule them, or remind: mail to them). The appropriate three Rs will be entered into the computer before the animal's departure.

 Any deferred or symptomatic care will be assigned to an attending nurse to follow up by telephone, until the condition/concern is resolved.

 Each doctor will schedule at least one grade 1+ dental prophy each shift, one grade 2+ dental a week, and one other dental for SIX per week minimum. Any new doctor will do the same.

Please see the following VCI® Signature Series Monographs for additional details and ideas about this subject:

 Medical Records for Quality & Continuity of Care

 Standards of Patient Care in Bond Centered Practice

 Professionalism, Bioethics, & Image

 Leadership Action Planner (core values & mission focus)

 Performance Planning in lieu of Performance Appraisals

 Zoned Systems & Schedules for Multi-doctor Hospitals