Editing Management of Care (section)

== Continuity of Care ==

Continuity of care is the coordinated, uninterrupted delivery of care as a patient moves across shifts, units, facilities, and levels of care. Most breakdowns occur at transitions.

=== Handoff communication ===
Handoff is the transfer of both information and responsibility. It should be a structured, interactive, face-to-face or synchronous exchange with an opportunity to ask questions, ideally with limited interruptions, and it should include the opportunity to review relevant data together. Inadequate handoff is a persistent contributor to sentinel events (The Joint Commission, 2017).

'''SBAR''' is the most widely tested structure (Haig et al., 2006):
* '''S'''ituation: who the patient is and what is happening right now.
* '''B'''ackground: the relevant clinical context, diagnosis, and history.
* '''A'''ssessment: what the nurse thinks the problem is.
* '''R'''ecommendation: what the nurse is asking the recipient to do.

A frequent examination point is that the '''R''' is not optional. A nurse who reports abnormal data without stating what is needed has not completed the communication.

'''Read-back.''' Verbal and telephone orders and critical laboratory values must be written down and '''read back''' to the sender for verification. Verbal orders should be reserved for emergencies and situations where the provider cannot access the record, and they must be authenticated by the provider within the time frame set by policy.

=== Transfer, discharge, and referral ===
'''Discharge planning begins on admission.''' It is interdisciplinary, and it is based on the patient's expected level of function, support system, home environment, finances, and health literacy. A transfer to another unit or facility requires a report to the receiving nurse, transfer of the record and medication list, and provider orders for the new setting.

'''Referrals''' connect the patient to resources outside the nurse's scope. Common referral targets tested on examinations include physical, occupational, and speech therapy; the registered dietitian for nutrition needs including swallowing-safe diets; the social worker for financial, housing, placement, and psychosocial resources; the case manager for coordination and utilization; respiratory therapy; the wound and ostomy nurse; the chaplain for spiritual needs; home health; and hospice. In most systems the RN may initiate a referral, while an order may be required for the service to be reimbursed.

'''Medication reconciliation''' occurs at admission, at every transfer between levels of care, and at discharge. It compares what the patient was actually taking, including over-the-counter drugs, herbals, and supplements, against what is ordered now.

=== Case management ===
The case manager coordinates care across the continuum for a defined population, monitors resource use and length of stay, arranges services, and works to prevent readmission. Case management is a coordinating role, not a bedside care role, and the case manager does not replace the bedside nurse's accountability.

=== Confidentiality and information security ===
Protected health information may be disclosed only to those with a legitimate need to know for treatment, payment, or health care operations, and only the '''minimum necessary''' for the purpose (Health Insurance Portability and Accountability Act of 1996). Practical rules that appear on examinations: do not discuss patients in elevators, hallways, or cafeterias; do not access the record of a patient not in your care, including a coworker, a family member, or yourself in many facilities; log off shared workstations; position screens away from public view; verify the identity and authorization of any caller before releasing information; and do not post anything about a patient on social media, including images that seem de-identified. A nurse may share information with another member of the treatment team caring for that patient. A nurse may not share it with a family member simply because the family member asks, absent the patient's authorization.