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)