Hospital Admissions and DC Summaries

Question 1

Things to not forget when writing Admissions Orders. (Hint: ADC VANDALISM)

Answer 1

Admit to service, ward, attending
Diagnosis
Condition (stable, fair, critical)
Vital Signs (get to say how frequently)
Allergy (food, drug)
Nursing Activities (suction, O2, weight)
Diet (post-sx)
Activity
Labs (as little as necessary)
IV and IV fluids
Special tests/procedures
Medication (Reconcile Home Rx)

Question 2

When is the patient ready to get discharged?

Answer 2

• Make sure pt is able to go home
• Planning for going home starts from day #1 of admissions
• Are all conditions better?
• Is everything started in hospital able to be stopped? (O2, telemetry, foley, IV)
• Is the home environment safe? (Fall prevention, help available, meds available, affordable?)

Question 3

Goals fo DC Summaries

Answer 3

• Documentation
• Communication
• Transfer of care, follow up
• Identify unresolved issues, future plans, data that is not yet complete (biopsies, tests, with pending results)

Question 4

Components of DC Summaries

Answer 4

• Admit Date
• DC date
• Admission Dx
• DC Dx
• Other Dx contributing to hospital state (not the main)
• Consults
• Procedures
• Hospital Summary
• Medication List (including changes, meds the patient is not longer supposed to take)
• DC Instruction (diets, wound care, activity, look out for)
• Follow Up (when will pt be seen, by whom, who f/u on testing)
• Any outstanding or pending issues