1. TECHNICAL COMMUNICATIONS IN THE MEDICAL SURGICAL NURSING UNIT

2.  First contact will be notice of an admission onto the unit, by Voice Care report.  Prepare standard floor chart (ie.. demographics, history & physical, medication lists, consent for treatment forms, release of information forms, and advance directives).  Patient room assigned by House Supervisor (person responsible for monitoring staff, patient, and available bed numbers).  Patient arrives on unit from transferring department (ie.. surgery, ER, ICU, L&D, or a cardiovascular unit ). MEDICAL SURGICAL NURSING UNIT

3. TO RESUSCITATE OR NOT TO? Always identify those patients who are DNR’s, or specific categories of resuscitation. The last thing you want to do, is go against a patient’s wishes.

4.  Patient information on electronic chart  Use to update established patient information, look at reports (ie.. Surgery, x-ray, labs, medication lists)  Communication between medical staff involved in direct patient care. Serves as a legal document for hospital and patient. COMPASS MEDICAL SOFTWARE

5.  This form will be the format on your screen in Compass  It is used at every patient admission, regardless, if they are a frequent flyer. PATIENT HISTORY & PHYSICAL

6.  This form is used to identify the pain or injury location, the patient is experiencing.  Please go over the pain scale with the patient, sometimes there pain maybe more/less intense than they can explain. ASSESSMENT FORM

7.  The Medical Consent form is used anytime a patient is admitted. This authorizes our healthcare staff to treat the patient.  There are various medical consent forms used (ie..Anethesia, surgery, blood products). Ensure the patient understands all risks pertaining to the appropriate procedure. CONSENT FOR TREATMENT

8. RELEASE OF INFORMATION  Release of information form (ROI) is used for obtaining, or sending private health information (PHI) specified by patient.  PHI should never be released without patient signed consent, or sent through a device which does not follow confidentiality rules.

9. ADVANCE MEDICAL DIRECTIVE  A written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out.  A living will allows you to document your wishes concerning medical treatments at the end of life.

10.  Utilize specified medical forms (use interpreter services if needed).  Every form serves a purpose in the patient electronic chart.  Remember : if you don’t chart it, then it wasn’t done!  Let’s focus on the patient, and not exhaust them with countless forms.  Use of the electronic chart enables this feature.  Our Goal: is to break the communication barrier, and keep it simple. CONCLUSION

11.  Seton Family of Hospitals © 1996-2013 Seton Healthcare Family www.seton.net/locations/seton_medical_center_williamson/ www.seton.net/locations/seton_medical_center_williamson/  Free Printable Medical Form Copyright © 2009-2013 by Savetz Publishing, Inc. www.freeprintablemedicalforms.com/Savetz Publishingwww.freeprintablemedicalforms.com/  Clip art © 2013 Clipart.com, a division of Getty Images http://www.clipart.com/en/Getty Images http://www.clipart.com/en/ CITATIONS