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 | ||
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***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''' | ||
*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 21:26, 24 June 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
- '''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)