TSICU:Clinical Documentation

• 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)