Name of the Procedure:

• Common Name: Skilled Nursing Observation and Assessment
• Medical Term: HCPCS Procedure Code G0163

Summary

Skilled services of a licensed nurse (LPN or RN) involve monitoring and evaluating a patient's condition every 15 minutes, especially when there is a significant change in the patient's health that requires professional assessment to determine further medical needs.

Purpose

• Medical Conditions: Designed to assess acute or worsening conditions such as sudden changes in vital signs, respiratory distress, or unusual symptoms that require immediate medical attention.
• Goals: The primary goal is to accurately identify changes in the patient's condition and provide timely interventions to prevent complications.

Indications

• Sudden changes in blood pressure, heart rate, or respiratory rate.
• New or worsening symptoms such as pain, shortness of breath, confusion, or weakness.
• Post-operative monitoring or after significant medical procedures.
• Patients with chronic conditions who exhibit acute exacerbations.

Preparation

• Pre-procedure Instructions: No specific instructions for patient preparation; however, patients should inform the nurse of any new symptoms or changes in their condition.
• Diagnostics: May include vital signs monitoring, blood tests, or other relevant diagnostic assessments as per the patient's medical history and presenting symptoms.

Procedure Description

1. Initial Assessment: The nurse conducts an initial assessment to establish a baseline of the patient's condition.
2. Observation: Every 15 minutes, vital signs and relevant health metrics are monitored.
3. Documentation: All findings are meticulously documented in the patient's medical records.
4. Evaluation: Continuous evaluation to identify any significant changes from the baseline.
5. Intervention: Based on the assessment, the nurse may administer medications, initiate additional monitoring, or communicate with the attending physician for further orders.

• Tools/Equipment: Stethoscope, blood pressure cuff, thermometer, pulse oximeter, patient charts, and electronic health records.
• Anesthesia/Sedation: Not applicable.

Duration

The duration varies based on the patient's needs and specific medical condition but involves periodic checks every 15 minutes for the required observation period, which can be hours or longer.

Setting

• Typically performed in settings like hospitals, outpatient clinics, long-term care facilities, or at the patient's home if receiving home health care services.

Personnel

• Licensed Practical Nurse (LPN)
• Registered Nurse (RN)

Risks and Complications

• Common Risks: Minimal but may include patient discomfort from frequent checks.
• Rare Risks: Errors in monitoring or documentation, delayed identification of a critical change in the patient's condition.

Benefits

• Expected Benefits: Immediate and accurate assessment of the patient's changing condition, leading to prompt interventions.
• Timeline for Benefits: Benefits are realized almost immediately as frequent monitoring allows for quick responses to health changes.

Recovery

• Post-Procedure Care: Will depend on the outcome of the assessments and any interventions required.
• Recovery Time: Not applicable as this is an observation and assessment procedure, not a recovery-based procedure.
• Restrictions/Follow-Up: Follow-up would be based on the patient's condition and any treatments initiated.

Alternatives

• Other Options: Less frequent monitoring by family members or caregivers, automated monitoring systems.
• Pros and Cons: Automated systems may lack the nuanced judgment of skilled nurses, while less frequent monitoring might miss important changes.

Patient Experience

• During the Procedure: Patients might feel regular interactions with the nurse for assessments, which can be reassuring or mildly uncomfortable due to frequent checks.
• Pain Management: Not typically required, but the nurse will manage patient comfort and address any concerns or discomfort during the assessments.