Hospital Admission, Transfers, and Rounding Flashcards
In order for the admission to be a true inpatient admission what criteria must be met?
Requires a specific diagnosis, condition, level of care required, and service/physician willing to accept patient
Who gets admitted?
Ultimately up to the gestalt of the provider
no clear checkboxes
What is the pneumonic for writing admission orders?
What do the letters stand for?
ADC VANDALISM
What is included in the diagnosis documentation in admission orders?
Should secondary conditions be included?
Include primary diagnosis that explains admission, along with other relevant diagnoses that will be managed/monitored during hosptial stay
Stable conditions and not actively being managed shouldn’t be included
A condition status of undertermined means what?
Not yet completely assessed
How often are vitals usually collected while inpatient?
Q4 hours
What does “up ad lib” indicate in orders?
Patient can get up whenever and do whatever
What are some diet considerations to document in admission orders?
- Consistency
- Restrictions
- NPO
- Nutrition consult
- Tube feeds or TPN
