April 15, 2021

CARE Record – learning more about patients

Hannah Conrick, Associate Nurse Unit Manager on Ward 16, looks after 32 patients on the ward, and oversees bed flow. As a surgical ward, Ward 16 also oversees patients coming from the Emergency Department, as well as elective surgery patients.

“That is why it is really important that we do CARE Records, as we do have a very big turnover of patients each day. On Monday, we had around 12 discharges and admissions,” she said.

Hannah says there are days when the team find it challenging to complete the record within the time constraints, but at the same time, they are learning more about our patients.

“With this record, there is no opportunity to miss anything – the questions are quite comprehensive,” she said.

The CARE Record, a document that has evolved over time, is a four page long questionnaire and prompts staff to ask various questions. It also looks at patient goals and what is important to them, in their care.

“The aim is to complete this document within 24 hours of admission, covering a range of topics, like falls risk, pressure injury risk, mental health, delirium screening, malnutrition screening and infection screening. It also looks at a patient’s dietary, cultural and language requirements,” she explained.

Abbey Beech, Clinical Nurse Specialist on the same ward, explained how the document evolved over time.

“When I just started, it was just a simple questionnaire, but now this multi-page document contains questions that include things like patient conditions at home, prompting us to put referrals in while they are here, and includes risk assessments that can get missed if we don’t ask the questions,” she explained.

Both Hannah and Abbey agree the document has contributed to patients feeling they are being listened to. With the diversity of cultures Northern Health sees, it is important to ask questions like family support at home, and similar, as it helps with discharge planning.

“We need to know early if a patient can’t manage their medications at home, or if they have some medical conditions we wouldn’t know about unless we asked those questions,” Abbey said.

One thing the team found very helpful is the mental health screening, as they are finding that it is flagging a significant amount of patients the team wouldn’t have known prior to the plan being in place.

“With the comprehensive care, we can put in place strategies if the patient is at a high suicide risk or shows signs of mental health deterioration,” Hannah explained.

“On top of the CARE Record, there are additional forms, so if a patient is flagged as having a risk, there are extra forms we fill out, to get detailed information and manage that risk,” Abbey added.

Featured image (left to right): Hannah Conrick and Abbey Beech