Table 1 Physician, Nurse, and Respiratory Therapist work definitions
Category | Includes | Excludes |
|---|---|---|
Direct Care Any activity directly related to patient care. | Admitting a patient Examining/reviewing a patient Performing medical procedures Assisting other staff with procedure Escorting a patient Communicating with patient/relative Taking a history | Medication related activities Documenting Reviewing documentation/results Planning care Communicating with staff member |
Note: All communication with patient/relative is defined as direct patient care. When the participant is discussing medications with a patient (e.g. as part of history taking and review), this is defined as a medication related event. | ||
Indirect Care Any activity indirectly related to patient care. | Reading & reviewing documents Planning care and ordering tests, diet etc. Running blood gases Retrieving information (from temporary or perm record, or computer) Checking results Washing hands Gathering & returning equipment Cleaning up after a procedure Watching monitors Find medical record-drop down Find x-ray/scan-drop down | Medication related activities Documenting in patient notes Communicating with staff member Communicating with patient/relative |
Note: Monitors, ventilators, and other electronic patient care equipment should be coded as 'computer'. | ||
Medication Any activity that relates to medication for a particular patient. | ||
Medication: Find Order | Looking for medication charts | Looking for notes in general |
Medication: Prescribe Drug | Writing up a new order Changing orders Receiving or requesting a verbal order Giving a verbal order Writing discharge scripts Obtaining drug authority numbers | Re-writing orders (e.g. legibility issues, needs signatures, etc.) Following a request for clarification (see Clarify) |
Medication: Transcribe Order | Copying med orders from one medication chart to new one (e.g. for end of week continuing meds) Transcribing verbal order | Re-writing orders (e.g. legibility issues, needs signatures, etc.) following a request for clarification (see Clarify) |
Medication: Prep Drug Activity around drug preparation & clean-up | Reading medication order to select drug Finding drug/or reconstitution fluid/or selection of appropriate equipment for preparation and administration Locating drug keys Preparing the drug (e.g. reconstitution, drawing up solution, crushing tablets, preparing nebulizers) Commencement and removal of IV infusions, cannulation, rearranging and disconnecting tubing for the purpose of drug administration Returning/disposing equipment &/or drug following administration S4/S8 counting & drug register entry for individual patients Checking the drug with other staff (when the participant who is being observed is responsible for the drug) Faxing/scanning order to pharmacy Re-ordering/re-filling drugs | Â |
Medication: Clarify Action taken when: Asked to clarify an order that has been previously written, or asking another doctor to clarify an order; or Seeking drug information for clarification (e.g. when prescribing) | Re-writing a drug order due to illegibility or legal reasons (or asking a doctor to re-write) Checking the particular drug details in Mims or other source asking another health professional about the drug order Clarifying with the patient about the drug order | Asking another nurse or doctor to check a drug that the observed participant wants to give (see Prep drug) |
Medication: Check Drug Checking with & co-signing of a nurse's or another doctor's medication | Witnessing any other medication for another health professional (e.g. IV a/b checks) Checking ID band &/or order &/or label | Asking another nurse or doctor to check a drug that the participant wants to give (see Prep drug) |
Medication: Administering/Charting Giving medication to a patient/recording drug administration details | Any patient preparation (e.g. sitting patient up so they can swallow medication, etc.) Reviewing &/or taking &/or documenting vital signs as part of the protocol before giving the medication (e.g. pulse prior to digoxin) Checking &/or adjusting IV admin throughout the administration process (e.g. returning to the pt & checking tubing, drip rate, etc.) Documenting on medication order notes Silencing IV pumps | Co-signing (see check-drug) Drug register (see Prep drug or Check drug) |
Medication: Discuss Talking about a drug with another health professional &/or patient/relative | Choice of drug &/or dosage Side effects Discharge education Efficacy Administration protocols | Clarification of an order (see Clarify) Requests for re-writing of order due to illegibility (see Clarify) |
Medication: Review | Looking over drug orders as part of planning care | Â |
Document Any recording of patient information on paper or computer. | Writing on temporary record (e.g. own list) Writing in patients' notes Getting physicians to sign-off on non-medication orders Discharge summaries-drop down | Medication chart documentation |
Professional Communication Any work-related discussion with another staff member. | Requesting medical or nursing consult or review Planning care with any health professional Handover/parts of a ward round | Medication related discussion Communication with patient/relative |
Administrative Any administrative activity that is not related to direct or indirect individual patient care. Also includes activities that relate to the running of the unit in general (but aren't related to direct or indirect patient care). | Duty rosters Employment issues Bed allocations Coordination of staff activities Staff meetings (not case or clinical meetings) Unit related Unit orders for stock | Handover Rounds |
In Transit Work related movement between patients and between tasks. | Movement when the participant exits a patient room | Movement between patients in a shared room Movement within a single room |
Note: When the participant arrives at another task or patient, "In Transit" ceases and the next appropriate category is chosen for that active task. e.g. participant leaves room to get equipment = in transit participant returns with equipment = indirect care | ||
Supervision/Education Active supervision or teaching of another staff member or student. | Attending education sessions (e.g. grand rounds) | Â |
Note: When the participant is actively supervising, "supervision" is selected and all tasks normally undertaken by the participant are added under "multi". | ||
Social Any social or personal activity or discussion. | Personal phone calls, tea & personal breaks Bathroom breaks Reading books/magazines | Â |
Pager Whenever the participant's pager alerts, pager is to be entered as an interruption. | Reading pager Returning call | Calling/having paged other healthcare providers (See Professional Communication) |