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 | **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) | ***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.) | ***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''' | '''Core Measures/Common Conditions''' | ||
'''Hospital Acquired Pressure Injuries (HAPIs)''' | '''Hospital Acquired Pressure Injuries (HAPIs)''' | ||
*Pressure injuries are to be documented in the medical record (size, stage) | *Pressure injuries are to be documented in the medical record (size, stage) | ||
*Consult wound care team for orders regarding wound care management | *Consult wound care team for orders regarding wound care management | ||
[[TSICU:FAST HUGS BID]] | [[TSICU:FAST HUGS BID]] | ||
**Ensure that this is completed for every TSICU patient daily | **Ensure that this is completed for every TSICU patient daily | ||
'''Code Status''' | '''Code Status''' | ||
*Clarify code status with patient or patient's next-of-kin, DPoA or SDM, as soon as feasible | *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 | *Ensure this is clarified on the medical record | ||
'''Advanced Directives''' | '''Advanced Directives''' | ||
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*'''Medication Reconciliation''' | *'''Medication Reconciliation''' | ||
**To be completed BOTH at the time of Admission to AND Transfer from the TSICU | **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) | **Safety Intelligence (SI) | ||
Revision as of 15:12, 19 July 2019
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
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
- 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)