TSICU:Clinical Documentation: Difference between revisions

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'''Admission History & Physical Exam'''
'''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.)


**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]]
'''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
 
 
'''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
 


*'''Core Measures/Common Conditions'''
'''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


*'''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]]
'''Advanced Directives'''
**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


*'''Medication Reconciliation'''
**To be completed BOTH at the time of Admission to AND Transfer from the TSICU


*'''Performance Improvement and Patient Safety'''
'''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


**Safety Intelligence (SI)
[[Category:Admin]]

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
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