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Admissions time savers
Prepared by: Ameen Al-Aghil PGY-2- Categorical
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Overall Admission steps
Check Vitals- Chief complaint – Triage if you have multiple admissions Quick chart review: ED note- last H&P/discharge summary Print latest med list available See patient, go over med list/pharmacies, don’t forget code status Admission orders – Pre-hold if still in ED Medication reconciliation Additional orders Consults H&P- note
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Flowsheet
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Overall Admission steps
Check Vitals- Chief complaint – Triage if you have multiple admissions Quick chart review: ED note- last H&P/discharge summary Print latest med list available See patient, go over med list/pharmacies, don’t forget code status Admission orders – Pre-hold if still in ED Medication reconciliation Additional orders H&P- note
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Overall Admission steps
Check Vitals- Chief complaint – Triage if you have multiple admissions Quick chart review: ED note- last H&P/discharge summary Print latest med list available See patient, go over med list/pharmacies, don’t forget code status Admission orders – Pre-hold if still in ED Medication reconciliation Additional orders H&P- note
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Admission orders Today- add the following order sets:
Admission order sets General: Admit order set CMC and ICU admission Cardiology: ACS order set Pulm: COPD Heme: Sickle cell crisis acute cmc Useful disease specific order sets Emergencies: Hyperkalemia, cord compression 911 and upper GI bleed Cardiology: Heart failure Pulm: Asthma, PE, Thoracentesis ID: Pneumonia, acute diarrhea, Neutropenic fever, acute meningitis and acute septic arthritis Rheumatology order set
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My favorite sets
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Overall Admission steps
Check Vitals- Chief complaint – Triage if you have multiple admissions Quick chart review: ED note- last H&P/discharge summary Print latest med list available See patient, go over med list/pharmacies, don’t forget code status Admission orders – Pre-hold if still in ED Medication reconciliation Additional orders Consults H&P- note
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Medication Rec! Very Important!
1- Outpatient Medication Review 2- Obtaining Accurate Medication list Patient/family EMR/ Pharmacy- next slide If came from SNF- Call SNF to FAX the list 3- Order Reconciliation
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Overall Admission steps
Check Vitals- Chief complaint – Triage if you have multiple admissions Quick chart review: ED note- last H&P/discharge summary Print latest med list available See patient, go over med list/pharmacies, don’t forget code status Admission orders – Pre-hold if still in ED Medication reconciliation Additional orders / Consults H&P- note
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ISBAR tool Identification: “ Hello, My name is Ameen with Weisman Team calling for a New consult, Pt is Name, location and MRN (three identifiers) Situation: Consult question, What is going on with the patient? Background: Context and relevant hx Assessment: State what you think the problem is. Recommendation: State your recommendation about what could be done to correct the problem.
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Overall Admission steps
Check Vitals- Chief complaint – Triage if you have multiple admissions Quick chart review: ED note- last H&P/discharge summary Print latest med list available See patient, go over med list/pharmacies, don’t forget code status Admission orders – Pre-hold if still in ED Medication reconciliation Additional orders / Consults H&P note: Chart review
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Chart review Specialty Teams: State who the Primary oncologist, nephrologist, cardiologist…. Refer to Student handbook for rotation specific instructions Physician portal- notes, EKG, prior Echo, EGD, Scopes (relevants) Clinical summary Medications received- useful for MICU/CICU transfers
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Clinical summary
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Medications
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Acronym expansion
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Questions?
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