Hospital Admissions and DC Summaries Flashcards Preview

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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

Components of DC Summaries

- 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