Hi Katie,
Do you write narrative RAP notes, or do you have a
question/answer type form that you fill out? Also, do you have a copy of
the Guidelines for each RAP at your desk? I have a set laminated, because
I use them so much. When I write a narrative RAP note, I go down the
Guidelines line by line for each RAP, and answer each item that is mentioned,
beginning with what triggered the RAP, then progressing through the guidelines,
ending with a care plan decision and supporting information for the care plan
decision.
Example: for a Delirium
RAP:
"Triggered due to deteriorated cognitive function, increased periods of lethargy and confusion. Mr. XXXX has diagnosis of Alzheimers dementia, history of CVA and diabetes. He has recently been treated for UTI. (See MD orders, Lab reports 11/15) He is afebrile, and there are no other significant medical conditions or diagnoses to address. Significant medications include Zyprexa, Ativan (prn) and Aspirin. (See MAR, Psychotropic RAP) There are no indications of sad or anxious mood, isolation, or depression, and there have been no recent changes in his environment or relationships. He does not use any physical restraints or devices. Hearing is adequate, and vision is functional for him. (See Vision RAP) Sleep pattern is consistent with his baseline function, although he has been noted to be lethargic more during the day over the past month.
"Triggered due to deteriorated cognitive function, increased periods of lethargy and confusion. Mr. XXXX has diagnosis of Alzheimers dementia, history of CVA and diabetes. He has recently been treated for UTI. (See MD orders, Lab reports 11/15) He is afebrile, and there are no other significant medical conditions or diagnoses to address. Significant medications include Zyprexa, Ativan (prn) and Aspirin. (See MAR, Psychotropic RAP) There are no indications of sad or anxious mood, isolation, or depression, and there have been no recent changes in his environment or relationships. He does not use any physical restraints or devices. Hearing is adequate, and vision is functional for him. (See Vision RAP) Sleep pattern is consistent with his baseline function, although he has been noted to be lethargic more during the day over the past month.
His decline in function has been gradual,
with more pronounced confusion over the past month. He was treated for UTI,
pending reevaluation after treatment. He is currently asymptomatic. His
room is kept quiet and well lit, and he has several items from home in his room,
to provide familiar surroundings.
There is no evidence of acute delirium;
rather his decline seems to be associated with progression of the Alzheimer's
dementia. Will continue to monitor for changes in cognitive function or
other indicators of delirium, and proceed to care plan to focus on intervening
as indicated."
Does this help at all? Email me privately if
you have further questions.
Holly Sox
----- Original Message -----
From: "katie fox" <[EMAIL PROTECTED]>
To: <[EMAIL PROTECTED]>
Sent: Thursday, November 20, 2003 2:45
PM
Subject: Basic RAP Help
>
> Hi Everyone,
> I was wondering if anyone has some helpful tips as to how to go about RAPS.
> I feel like I am repeating myself and I do not feel like they are good. So,
> I am asking experienced MDS people to give me some direction.
> Thank You,
>
> Katie Fox, RN
> Seaview Nursing and Rehabilitation Facility
> St. Thomas, Virgin Islands
> 340-777-3303 ext. 114
>
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