Flashcards in Hospital Admissions and DC Summaries Deck (4)
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1
Things to not forget when writing Admissions Orders. (Hint: ADC VANDALISM)
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)
2
When is the patient ready to get discharged?
- 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?)
3
Goals fo DC Summaries
- Documentation
- Communication
- Transfer of care, follow up
- Identify unresolved issues, future plans, data that is not yet complete (biopsies, tests, with pending results)
4
