TSICU:Clinical Documentation - Revision history

Rossdonaldson1 at 21:57, 31 August 2022

2022-08-31T21:57:30Z

← Older revision		Revision as of 21:57, 31 August 2022
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	**The VMB is run every Wednesday at 3:00pm		**The VMB is run every Wednesday at 3:00pm
	**ALL STAFF are welcomed and encouraged to actively participate in unit processes and function		**ALL STAFF are welcomed and encouraged to actively participate in unit processes and function

			[[Category:Admin]]

Dykim at 19:59, 20 July 2019

2019-07-20T19:59:09Z

← Older revision		Revision as of 19:59, 20 July 2019
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	'''[[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

Dykim at 19:58, 20 July 2019

2019-07-20T19:58:36Z

← Older revision		Revision as of 19:58, 20 July 2019
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	'''Advanced Directives'''		'''Advanced Directives'''


	'''Medication Reconciliation'''		'''Medication Reconciliation'''

Dykim at 19:44, 19 July 2019

2019-07-19T19:44:10Z

← Older revision		Revision as of 19:44, 19 July 2019
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	*3W TSICU was the first inpatient unit to roll out the Visual Management Board (VMB)		*3W TSICU was the first inpatient unit to roll out the Visual Management Board (VMB)
	**The VMB is run every Wednesday at 3:00pm		**The VMB is run every Wednesday at 3:00pm
			**ALL STAFF are welcomed and encouraged to actively participate in unit processes and function

Dykim at 19:43, 19 July 2019

2019-07-19T19:43:11Z

← Older revision		Revision as of 19:43, 19 July 2019
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	'''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)
	**3W TSICU was the first inpatient unit to roll out the Visual Management Board (VMB)		*3W TSICU was the first inpatient unit to roll out the Visual Management Board (VMB)
	***The VMB is run every Wednesday at 3:00pm		**The VMB is run every Wednesday at 3:00pm

Dykim at 19:42, 19 July 2019

2019-07-19T19:42:30Z

← Older revision		Revision as of 19:42, 19 July 2019
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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)
	**A comprehensive history and physical exam is to be completed for every patient at the time of TSICU admission		**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.)
	***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.)


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	[[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

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


	**Safety Intelligence (SI)		**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

Dykim at 15:12, 19 July 2019

2019-07-19T15:12:51Z

← Older revision		Revision as of 15:12, 19 July 2019
Line 1:		Line 1:


	'''Admission History & Physical Exam'''		'''Admission History & Physical Exam'''

Dykim at 15:12, 19 July 2019

2019-07-19T15:12:34Z

← Older revision		Revision as of 15:12, 19 July 2019
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	'''Admission History & Physical Exam'''		'''Admission History & Physical Exam'''

Dykim at 15:12, 19 July 2019

2019-07-19T15:12:10Z

Dykim at 22:20, 18 July 2019

2019-07-18T22:20:13Z

← Older revision		Revision as of 22:20, 18 July 2019
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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'''