GUIDELINE FOR  USE OF PROTOCOL FORM

Key Point:       Protocols are documentation tools used and reviewed by RNs each shift.   Protocols are a permanent part of the medical record.

Key Point:      Protocols are based on current evidence based practice initiatives.  Modifications of protocols should be minimal and based on the patient’s individual needs.

 INSTRUCTIONS:

1. Place patient’s identification sticker on upper right hand corner.

2. Review Patient Outcome Statements for appropriateness to individual patient.  If applicable, document additional Patient Outcome Statements in space provided.

3. Record initiation date, time, signature and title of person implementing the protocol.

4. Record discontinuation date, time, signature and title of person discontinuing protocol when no longer applicable.

5. Review content in assessment, intervention and evaluation columns.  Content changes may be made based on individual patient needs/input, MD orders and nursing judgment.

6. Changes are made on the protocol by:

1. Placing a single line through content statement(s) that is not applicable

2. Writing content statement(s) under appropriate heading that is applicable to the individual patient

3. Placing single line through part of the content statement and replace with individual criteria based on  MD order and/or patient needs

4. Initialing all changes 

7. Record date, time and initials in appropriate columns to reflect when protocol modifications are made and by whom.

KEYPOINT:  Complete initial education assessment on the Multidisciplinary Patient Education Form (MDPEF) within 24 hours of admission of the first teaching encounter. Teaching items not specific to the protocol are documented on the MDPEF.  Refer to Guideline HHH for MDPEF.

8. Write the date the instruction was given in the space provided.

9. Write your name and title in the space provided.

10.  Topics that should be taught for each protocol are listed under topic taught.  In the space provided, write the number of the topic(s) that relates best to the education that was provided.

11. List the educational materials that were used and topics discussed in the space provided.

Keypoint: Refer to the Key to Teaching Section of Protocol for all codes used in the    documentation in the teaching session on their form.

12. Identify the recipient(s) of the teaching in the space provided.

13. Write either the method(s) of teaching that was utilized or write the codes pertaining to these  methods using the Teaching Method codes.

14. Write in the Motivation Level of the patient at the time of the teaching encounter, using the Motivation Level codes at the end of the MDPEF.

15. Indicate the Barriers to Learning at the time of the teaching and how the barriers were addressed, using the Barriers and Addressing Barriers codes (example: Patient who does not speak English: L/T). If no barriers exist, you must write N/N in the space provided - do not leave blank.

16. Complete this section using the Learner Response codes listed at the top of the MDPEF.

RESOURCE PERSON(S):     

Pam LaBorde, RN,CNS, MSN; Joyce Randof RN, MNSc, BC