View source for TSICU:Clinical Documentation



'''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)
**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]]
*This AdHoc Note is to be completed every day and PRIOR to starting the daily ICU Progress Note


'''Core Measures/Common Conditions'''


'''Hospital Acquired Pressure Injuries (HAPIs)'''
*Pressure injuries are to be documented in the medical record (size, stage)
*Consult wound care team for orders regarding wound care management


'''[[TSICU:FAST HUGS BID]]'''
*Ensure that this is completed for every TSICU patient daily


'''Code Status'''
*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


'''Advanced Directives'''


'''Medication Reconciliation'''
*To be completed BOTH at the time of Admission to AND Transfer from the TSICU


'''Performance Improvement and Patient Safety'''
*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
**ALL STAFF are welcomed and encouraged to actively participate in unit processes and function