IHE Patient Care Coordination Technical Framework Vol I

PCC Technical Framework V3.0, vol. 1
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Use Case Overview
A recently widowed 75 year old woman is admitted to an adult inpatient floor of a
behavior health hospital for depression post suicide attempt
1. A 75 year old woman who lives alone and has become increasingly withdrawn
since the sudden death of her husband 6 weeks ago took several days worth of
medication at one time from her pill pack. A neighbor found the confused
elderly woman in the woman's home, and immediately took her to her
psychiatrists office. Patient was diagnosed as depressed by her psychiatrist, and
was a direct admission from her doctor's office to an adult inpatient floor in a
behavioral health facility.
2. Psychiatrist notes patient issue regarding depression into electonic health record
notes.
3. Patient screened by adult inpatient admission nurse using the geriatric
depression scale. Her initial score was 26, indicating severe depression. Patient
information was entered into the electronic health record. Patient states that she
has a hard time getting going each day and is afraid of how she will survive
without her husband. She has lost her appetite and is unhappy with her life
without her husband.
1. Nurse documents geriatric depression scale results in the electronic health
record.
2. Nurse documents patient's feelings and concerns in progress notes in the
electronic health record.
3. Nurse initiates plan of care for management of depression.
4. Psychiatrist reviews the patient's progress and visits patient. Psychiatrist orders
anti-depressant and mood stabilizer medications via CPOE.
5. Social work evaluates the patient for her social support and financial status. The
patient has no limitations in activity of daily living. She has a housekeeper come
in monthly to clean and does her own grocery shopping and laundry weekly.
Her nearest relative is over 1,000 miles away and her only support network are
friends and neighbors that are also frail and elderly. The social worker also
collaborates with the nurse regarding the signs of depression and the geriatric
depression scale score. The plan of care is updated by the social worker and
discharge planning begins.
6. Daily, nursing gives patient medication and assesses the patient's depression
status using the geriatric depression scale. Interventional therapy sessions
provided to patient to improve mood and outlook for the future.
1. Nurse documents administration of medication.
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Revision 3.0 Public Comment — June 25, 2007
Copyright © 1997-2007: ACC/HIMSS/RSNA