TSICU:Clinical Documentation: Difference between revisions

Latest revision as of 21:57, 31 August 2022

Admission History & Physical Exam

A comprehensive history and physical exam is to be completed for every patient at the time of TSICU admission
- Use multiple sources of data to complete the history (ER and trauma H&P; family members/loved ones; EHR)
- For trauma patients, it is important to document an Injury Inventory and to keep track of the status of consult services (i.e. consulted, NOT assessed; consulted, assessed, awaiting recs, etc.)

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 this 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

To be completed BOTH at the time of Admission to AND Transfer from the TSICU

Performance Improvement and Patient Safety

Safety Intelligence (SI)
3W TSICU was the first inpatient unit to roll out the Visual Management Board (VMB)
- The VMB is run every Wednesday at 3:00pm
- ALL STAFF are welcomed and encouraged to actively participate in unit processes and function

Authors:

@@ Line 1: / Line 1: @@
-*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
+'''Admission History & Physical Exam'''
-*Hospital Acquired Pressure Injuries (HAPIs)
+*A comprehensive history and physical exam is to be completed for every patient at the time of TSICU admission
-**Pressure injuries are to be documented in the medical record (size, stage)
+**Use multiple sources of data to complete the history (ER and trauma H&P; family members/loved ones; EHR)
-**Consult wound care team for orders regarding wound care management
+**For trauma patients, it is important to document an Injury Inventory and to keep track of the status of consult services (i.e. consulted, NOT assessed; consulted, assessed, awaiting recs, etc.)
-*[[TSICU:FAST HUGS BID]]
-**Ensure that his is completed for every TSICU patient daily
-*Code Status
+'''Adult ICU Progress Note Required Details''' [[Media:Ad Hoc.jpg]]
-**Clarify code status with patient or patient's next-of-kin, DPoA or SDM, as soon as feasible
+*This AdHoc Note is to be completed every day and PRIOR to starting the daily ICU Progress Note
-**Ensure this is clarified on the medical record
-*Advanced Directives
-*Medication Reconciliation
+'''Core Measures/Common Conditions'''
-*Performance Improvement and Patient Safety
-**Safety Intelligence (SI)
+'''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 this 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'''
+*To be completed BOTH at the time of Admission to AND Transfer from the TSICU
+'''Performance Improvement and Patient Safety'''
+*Safety Intelligence (SI)
+*3W TSICU was the first inpatient unit to roll out the Visual Management Board (VMB)
+**The VMB is run every Wednesday at 3:00pm
+**ALL STAFF are welcomed and encouraged to actively participate in unit processes and function
+[[Category:Admin]]