TSICU:Clinical Documentation: Difference between revisions
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*Admission History & Physical Exam | |||
*Adult ICU Progress Note Required Details [[Media:Ad Hoc.jpg]] | *Adult ICU Progress Note Required Details [[Media:Ad Hoc.jpg]] | ||
**This AdHoc Note is to be completed every day and PRIOR to starting the daily ICU Progress Note | **This AdHoc Note is to be completed every day and PRIOR to starting the daily ICU Progress Note | ||
Revision as of 18:58, 24 June 2019
- Admission History & Physical Exam
- Adult ICU Progress Note Required Details Media:Ad Hoc.jpg
- This AdHoc Note is to be completed every day and PRIOR to starting the daily ICU Progress Note
- Core Measures/Common Conditions
- Hospital Acquired Pressure Injuries (HAPIs)
- Pressure injuries are to be documented in the medical record (size, stage)
- Consult wound care team for orders regarding wound care management
- TSICU:FAST HUGS BID
- Ensure that his is completed for every TSICU patient daily
- Code Status
- Clarify code status with patient or patient's next-of-kin, DPoA or SDM, as soon as feasible
- Ensure this is clarified on the medical record
- Advanced Directives
- Medication Reconciliation
- Performance Improvement and Patient Safety
- Safety Intelligence (SI)