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Indian Health Service The Federal Health Program for American Indians and Alaska Natives

Standard Code Book (SCB)  

Patient Education Protocol

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1-25 of 3874 items displayed
 
  

Code Topic Subtopic Outcome Standards
ABD-AP   ABDOMINAL PAIN  ANATOMY AND PHYSIOLOGY  The patient/family will understand anatomy and physiology as they relate to abdominal pain.  1.Explain the normal anatomy and physiology of the pertinent abdominal organs. Generally, they can be categorized as the hollow digestive organs (stomach, intestines, appendix, gallbladder), solid digestive organs (liver, pancreas), reproductive organs (uterus/ovaries, prostate), urologic organs (kidneys, bladder), spleen, peritoneum, muscles of the abdominal wall (hernias), blood vessels (aorta). 2. Discuss the changes to anatomy and physiology as a result of abdominal pain. 3. Discuss the impact of these changes on the patient's health or well-being. 
ABD-C   ABDOMINAL PAIN  COMPLICATIONS  The patient/family will understand the complications of abdominal pain.  1.Explain that some possible complications are acute hemorrhage, sustained hypotension and shock, perforation of an organ, and infections. 2.Advise the patient/family that complications may be prevented with prompt treatment. Increasing-pain, persistent fever, bleeding, or altered level of consciousness should prompt immediate follow-up. 
ABD-DP   ABDOMINAL PAIN  DISEASE PROCESS  The patient/family will understand some possible etiologies of abdominal pain.  1. Discuss various etiologies for abdominal pain, e.g., gastritis or peptic ulcer, constipation, appendicitis, diverticulitis, pancreatitis, peritonitis, gastroenteritis, bowel obstruction, ruptured aneurysm, ectopic pregnancy, and inflammatory bowel disease, as appropriate. 2.Discuss the causes, course, and expected outcome as it pertains to the patient's particular abdominal pain. 
ABD-FU   ABDOMINAL PAIN  FOLLOW-UP  The patient/family will understand the importance of follow-up in the treatment of abdominal pain.  1.Emphasize the importance of follow-up care. 2.Discuss the procedure and process for obtaining follow-up appointments. 3.Emphasize that full participation in the treatment plan is the responsibility of the patient/family. 4.Discuss the signs/symptoms that should prompt immediate follow-up. 5.Discuss the availability of community resources and support services and refer as appropriate. 
ABD-L   ABDOMINAL PAIN  LITERATURE  The patient/family will receive literature about abdominal pain.  1.Provide the patient/family with literature on abdominal pain. 2.Discuss the content of the literature. 
ABD-M   ABDOMINAL PAIN  MEDICATIONS  The patient/family will understand the purpose, proper use, and expected outcomes of the prescribed medication therapy.  1.Describe the name, strength, purpose, dosing directions, and storage of the medication. 2.Discuss the risks, benefits, and common or important side effects of the medication and follow up as appropriate. 3.Discuss any significant drug/drug, drug/food, and alcohol interactions, as appropriate. 4.Discuss the importance of full participation with the medication plan and that this is the patient's responsibility. Discuss any barriers to full participation. 5.Discuss the importance of keeping a list of all current prescriptions and over-the-counter medicines, vitamins, herbs, traditional remedies, and supplements. Encourage the patient to bring this list, inhalers, and pill bottles to appointments for medication reconciliation. 
ABD-MNT   ABDOMINAL PAIN  MEDICAL NUTRITION THERAPY  The patient/family will understand the specific nutritional intervention(s) needed for the treatment or management of abdominal pain.  1. Explain that Medical Nutrition Therapy (MNT) is a systematic nutrition care process provided by a Registered Dietitian (RD). 2. Review the basic nutrition recommendations for the treatment plan. 3. Discuss the benefits of nutrition and exercise to health and well-being. 4. Assist the patient/family in developing an appropriate nutrition care plan. 5. Refer to other providers or community resources as needed. 
ABD-N   ABDOMINAL PAIN  NUTRITION  The patient/family will understand nutrition in abdominal pain.  1.Emphasize that nutritional management includes meal planning, careful shopping, appropriate food preparation, and eating. 2.Describe healthy food preparation methods. Emphasize the importance of appropriate serving sizes and reading food labels. 3.Discuss the importance of regular meals and adequate fluid intake. 4.Explain that oral supplements are beneficial to boost calories if oral intake is less than optimal. 5.Discuss as appropriate: a.Avoid possible foods that may exacerbate abdominal pain. b.Omit possible offenders such as alcohol, caffeine, and aspirin. c.Explain the benefits of keeping a food diary to identify foods that may be associated with pain. 6.Refer to a registered dietitian for MNT. 
ABD-PM   ABDOMINAL PAIN  PAIN MANAGEMENT  The patient/family will understand pain management in abdominal pain.  1.Explain the pain scale and how it is used to assess the degree of pain individuals are experiencing. Discuss its use in developing a plan to manage pain. 2.Explain that pain management is specific to the disease process and the patient, and it may be multifaceted. Refer to PM. 3.Explain that fluids, non-pharmacologic measures, and medications may be helpful to control pain and the symptoms associated with pain, such as nausea and vomiting. 4.Explain non-pharmacologic measures that may be helpful with pain control. 5.Discuss, as appropriate, that some foods might exacerbate abdominal pain. Refer to ABD-N. 6.Explain that administration of fluids, narcotics, other medications and non-pharmacologic measures may be helpful in managing pain and associated symptoms. 
ABD-SM   ABDOMINAL PAIN  STRESS MANAGEMENT  The patient/family will understand the role of stress management in the treatment of abdominal pain.  1. Discuss that uncontrolled stress may increase alcohol and other drug use and interfere with the treatment. 2. Emphasize the importance of seeking professional help as needed to reduce stress. 3. Discuss various stress management strategies such as maintaining a healthy lifestyle. Some examples may include: a. becoming aware of your own reactions to stress b. recognizing and accepting your limits c. talking with people you trust about your worries or problems d. setting realistic goals e. getting enough sleep f. maintaining a healthy diet g. exercising regularly h. taking breaks or vacations from everyday routine i. practicing meditation, self-hypnosis, and positive imagery j. practicing physical relaxation methods such as deep breathing or progressive muscular relaxation k. participating in spiritual or cultural activities 4. Provide referrals as appropriate. 
ABD-TE   ABDOMINAL PAIN  TESTS  The patient/family will understand the test(s) to be performed, the potential risks, the expected benefits, and the risks of non-testing.  1.Explain test(s) that have been ordered (explain as appropriate): a.method of testing b.necessity, benefits, and risks of test(s) to be performed c.any potential risk of refusal of recommended test(s) d.any advance preparation and instructions required for the test(s) e.how the results will be used for future medical decision-making f.how to obtain the results of the test 2.Explain test results: a.meaning of the test results b.follow-up tests may be ordered based on the results c.how results will impact or effect the treatment plan d.recommendations based on the test results 
ABD-TX   ABDOMINAL PAIN  TREATMENT  The patient/family will understand the treatments that may be prescribed including the risk and benefits of the treatments or the risk of non-treatment.  1.Explain the treatment plan. Emphasize the importance of active participation by the patient/family in the development of and participation in the treatment plan. 2.Discuss the therapies that may be utilized. 3.Explain that various treatments have their own inherent risks, side effects, and expected benefits. Explain the risk/benefit of treatment and non-treatment. 4.Discuss the importance of maintaining a positive mental attitude. 
ABNG-BH   ABUSE AND NEGLECT (CHILD OR ELDER)  BEHAVIORAL AND EMOTIONAL HEALTH  The patient/family will understand the behavioral, emotional, and psychological components to abuse and neglect.  1.Discuss the common difficulty in coping with the initial impact of abuse and neglect, which may require a change in lifestyle. 2.Discuss the potential stress, anger, sadness, fear, and/or other emotional reactions that are common in abuse and neglect, and the danger of further complications or mental health diagnoses related to untreated emotional turmoil. 3.Discuss that the healing process incorporates traditional medical, spiritual, mental/emotional, and cultural components. 4.Discuss the danger of denial about the diagnosis, and the importance of seeking help in accepting and coping with the illness. 5.Discuss the potential of dangers of self-medication of emotional disturbance with tobacco, alcohol, or other drugs. Refer to AOD. 6.Refer to a mental health agency or provider. 
ABNG-C   ABUSE AND NEGLECT (CHILD OR ELDER)  COMPLICATIONS  The patient/family will understand the effects and consequences of abuse and neglect.  1.Discuss that abuse and neglect may result in death, serious physical, or emotional harm to the victim. 2.Explain that abuse and neglect are actions punishable by law. 
ABNG-CUL   ABUSE AND NEGLECT (CHILD OR ELDER)  CULTURAL/SPIRITUAL ASPECTS OF HEALTH  The patient/family will understand the impact and influences that cultural and spiritual traditions, practices, and beliefs have on health and wellness.  1.Discuss the potential role of cultural/spiritual traditions, practices and beliefs in achieving and maintaining health and wellness. Refer to clergy services, traditional healers, or other culturally appropriate resources. 2.Explain that traditional medicines/treatments should be reviewed with the healthcare provider to determine if there are potential interactions with prescribed treatment. Explain that the medical treatment plan must be followed as prescribed to be effective. 
ABNG-EC   ABUSE AND NEGLECT (CHILD OR ELDER)  EMERGENCY CONTRACEPTION (POST-COITAL)  The patient/family will understand emergency contraception that is presented in a non-judgmental manner.  1. Explain the process of obtaining emergency contraception. a. Many options are available and include prescription and non-prescription medications. b. May be available via collaborative practice agreements from non-primary care providers, i.e., nurses and pharmacists. c. Patients under 17 years of age, may require a prescription. 2. Discuss perceptions regarding emergency contraception. Emergency contraception a. is not an abortion and is not an “abortion pill” b. will not affect an existing pregnancy and will not work if a woman is already pregnant c. will not protect against sexually transmitted infections d. should not be used as a regular birth control method e. is less effective than correctly used birth control options - it is considered only a backup or emergency method 3. Explain that many different medicines may be used as emergency contraception. Regardless of the exact medicine chosen, the mechanisms of actions are similar and include: a. Stopping the release of an egg from the ovary b. Preventing fertilization of an egg c. Preventing attachment of a fertilized egg to the uterus 4. Explain the proper use of emergency contraception. a. It is most effective if started as soon as possible and ideally within 72 hours of unprotected sexual intercourse or contraceptive failure. These include: i. The regular birth control method was used incorrectly or failed (condom broke or slipped) ii. A mistake was made with the regular birth control method iii. No birth control method was used b. Longer intervals (120 hours = 5 days) may be considered, but efficacy rates are significantly decreased. c. The medicine must be taken exactly as prescribed to maximize efficacy. 5. Explain situations that require follow up by a medical provider. These include but are not limited to: a. Vomiting that occurs within one hour of a dose of emergency contraception b. A menstrual period that is more than 7 days late c. Any side effects that persist or worsen d. Any severe abdominal pain 3 to 5 weeks after taking emergency contraception - this could be symptoms of a life threatening tubal pregnancy e. Any emotional disturbances, but especially in the setting of sexual assault and other traumatic experiences 6. Review common or important side effects of emergency contraception. a. Most side effects are mild and temporary. They may include menstrual changes, nausea, abdominal pain, tiredness, headache, dizziness, breast pain and vomiting. b. Some women will have menstrual changes (spotting before next period, heavier, lighter, earlier or later). If the period is more than a week late, a pregnancy test should be obtained. 
ABNG-FU   ABUSE AND NEGLECT (CHILD OR ELDER)  FOLLOW-UP  The patient/family will understand the importance of follow-up in abuse and neglect cases.  1.Emphasize the importance of follow-up care. 2.Discuss the procedure and process for obtaining follow-up appointments. 3.Emphasize that full participation in the treatment plan is the responsibility of the patient/family. 4.Discuss the signs/symptoms that should prompt immediate follow-up. 5.Discuss the availability of community resources and support services and refer as appropriate. 
ABNG-HELP   ABUSE AND NEGLECT (CHILD OR ELDER)  HELP LINE  The patient/family will understand how to access and benefit from a help line or Internet website regarding abuse and neglect.  1.Explain that support groups and reliable information may assist in answering questions regarding abuse and neglect and dealing with issues. 2.Provide the help line phone number or Internet address (URL). 
ABNG-L   ABUSE AND NEGLECT (CHILD OR ELDER)  LITERATURE  The patient/family will receive literature about abuse and neglect.  1.Provide the patient/family with literature on abuse and neglect, which may include safety procedures (refer to ABNG-S), and a list of private and public treatment programs. 2.Discuss the content of the literature. 
ABNG-N   ABUSE AND NEGLECT (CHILD OR ELDER)  NUTRITION  The patient/family will understand nutrition, as it relates to abuse and neglect.  1.Emphasize that nutritional management includes meal planning, careful shopping, appropriate food preparation, and eating. 2.Describe healthy food preparation methods. Emphasize the importance of appropriate serving sizes and reading food labels. 3.Discuss use of food as a coping mechanism and it role in eating disorders. 4.Refer to registered dietitian for MNT or other local resources as appropriate. 
ABNG-P   ABUSE AND NEGLECT (CHILD OR ELDER)  PREVENTION  The patient/family will understand ways of preventing abuse and neglect.  1. Explain that education about abuse and neglect to potential victims (child and elders and caretakers) is an essential part of prevention. 2. Explain that parenting classes may help develop skills for preventing emotional and behavioral complications (refer to ABNG-PA). 3. Refer to behavioral health or social services for caretaker skills, as needed. 
ABNG-PA   ABUSE AND NEGLECT (CHILD OR ELDER)  PARENTING  The parent(s)/family will understand parenting skills necessary to meet the physical and emotional needs of children, thereby reducing the risk of child abuse/neglect.  1.Discuss methods for appropriate parenting at home. 2.Emphasize the importance of communicating in a way that the child understands. 3.Discuss the importance of providing emotional support and unconditional assistance to the child. 4.Refer the family to mental health services/ family counseling if the family is becoming overwhelmed. 
ABNG-RI   ABUSE AND NEGLECT (CHILD OR ELDER)  PATIENT RIGHTS AND RESPONSIBILITIES  The patient/family will understand the rights and responsibilities of victims, reporters, and potential assailants.  1.Discuss patient rights to privacy and confidentiality as it relates to patient/family safety and mandatory reporting laws for providers, as appropriate. 2.Discuss that all persons have the right to a life free of abuse and neglect. 3.Identify methods and resources to enhance patient safety. For elder abuse, find ways of maintaining the patient's autonomy and independence as appropriate. 
ABNG-RP   ABUSE AND NEGLECT (CHILD OR ELDER)  MANDATORY REPORTING  The patient/family will understand the process of mandatory reporting.  1.Emphasize the importance of reporting suspected abuse and neglect to the proper law enforcement and child welfare/protective agencies and the patient's healthcare provider. 2.Explain that mandatory reporting is necessary to ensure the safety of all children and adults. 3.Explain that requirements for mandatory reporting vary by state. Some states require reporting for "reasonable cause to believe" while others require reported for known or suspected" abuse or neglect. 4.Explain that states require healthcare provider, mental healthcare providers, teachers, social workers, day care providers, and law enforcement personnel to report suspected abuse or neglect. 5.Explain that failure to report such information may result in criminal or civil liability for the provider. 
ABNG-S   ABUSE AND NEGLECT (CHILD OR ELDER)  SAFETY  The patient/family will understand safety as it relates with abuse and neglect situations.  1.Discuss the behaviors that constitute abuse and neglect, and help define safe and healthy ways of intervening with victim(s). 2.Emphasize the importance of reporting suspected abuse and neglect. Refer to ABNG-RP. 3.Assist to develop a plan of action that will ensure safety of all people in the environment of violence. 4.Explain the need for the family to develop a safety plan for the victim(s). 
 3874 Record(s)

 
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