IHE Patient Care Coordination Technical Framework Vol I

PCC Technical Framework V3.0, vol. 1
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Use Case Scenario
1. A 76 year old resident/patient of a LTC facility has become increasingly weak,
lethargic and has a low-grade fever. Resident refuses to get out of bed and is
complaining of chills and the nurse noted reddened area on coccyx during
assessment. Resident's glucose level is elevated and the maximum sliding-scale
dose indicated in medication order is not controlling blood sugar.
1. Nurse documents vital signs.
2. Nurse documents finger-stick glucose measurement.
3. Nurse documents current functional assessment.
4. Nurse documents braden score.
5. Nurse initiates phone collaboration with Primary Care Provider (PCP).
6. Primary care provider(PCP)and nurse review patient status information on the
electronic health record (EHR). Note: Interdisciplinary collaboration supports
evaluation of physiologic changes and critical thinking leading to early
intervention.
7. PCP enters transfer order to acute care facility via computerized physician
order entry (CPOE).
2. The patient's baseline and serial functional assessment data is sent to the acute
care hospital via a document exchange server.
1. Nurse admission coordinator reviews transfer documents via the EHR. Note:
Early comprehensive patient information availability allows the admission
coordinator to assign appropriate unit and adjust staffing based on potential
acuity. Appropriate nurse to patient acuity staffing ratios support both staff
and patient safety, reducing risk of errors.
2. Bed is assigned on medical floor at acute care facility, pending admission is
sent to charge nurse on the medical floor.
3. Charge nurse reviews the patient's functional status assessment data, VS,
glucose values and braden score from LTC facility. Note: The charge nurse is
provided additional time to reassign other patients and/or allowing the admitting
nurse more time to prepare for the patient admission.
1. Based on the information reviewed, Charge nurse adjusts shift assignment
based on patient’s level of care.
4. Patient arrival to medical floor at acute care facility.
1. Admitting nurse takes patient VS and completes admission assessment in
EHR. Note: Nurse compares serial EHR preadmission assessments to new
admission assessment data. Serial EHR assessments allow nurse to compare
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Revision 3.0 Public Comment — June 25, 2007
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