ED Admit to Inpatient Rm
ATT: @ATTPROV@
PCP: @PCP@
@NAME@ @AGE@(@BDAY@)
@DEPTNME@
@RRHLOS@
MRN: @MRN@
Current attending in ED: @ATTPHY@
SYNOPSIS
@VISITINFOCC@
@VISITINFOHPI@
@NAME@ is a @AGE@ @SEX@ ***
@NOTESUMMARIES(1&0&0)@
DX:
@PROB@
RN CONCERNS, UPDATES
•
ASSESSMENT
NEURO:
• Aoxo4
RESPIRATORY:
• No SOB on room air?
o Supplemental Oxygen?: 14744
• O2 sats: @FLOWSTAT(5006:24)@
•
Blood Gases:
{ISTAT BLD GAS ART:16466}
Vent Settings:
@FLOWDATI(9301)@
.
CARDIAC:
•
@EKGRESULTS@
• GI:
o swallows pills ok
- On Diabetic Protocol? (Assume yes if A1c > 6)
@DIETORD@
• last BM PTA
• GU:
o uses urinal or purewick
@IOBRIEF@
• SKIN/MS:
o normal for ethnicity
o moves all extremities
o ambulatory:
o Placed on a hospital bed in ED?: yes
• FAMILY:
o at bedside?
NURSING HANDOFF
NOTES ENDORSED TO RECEIVING NURSE:
• Controlled meds given this shift:
Plan: Pending workup/admit . All questions answered to the patient’s satisfaction. All personal belongings were with the patient including all electronics, clothing, and valuables. Pt sent w/medical paperwork. Charge RN aware.
DISPO: NAD, VSS
BELONGINGS: clothing and cell phone
REPORT GIVEN TO: RN
TRANSPORTATION: gurney via tech
DESTINATION: tbd
LABS
@LABRCNT24(POCGLUCOSE:*)@
{SNP Linked Labs:23727}
@LABBRIEF(NA,CL,BUN,K,CO2,CREATININE,GLUCOSE)@
@LABBRIEF(WBC,HGB,HCT,PLATELETS)@
@LABBRIEF(PT,INR,APTT)@
@LABBRIEF(CA,MG,PHOS)@
@LABBRIEF(ALB,LACTICACID,LACTWBVENPC,TROPONINHS,HGBA1C)@
@LABSPENDING@
@LABBRIEF(SARSCOV,INFLUENZAA)@
VITALS
VITALS
24 Hour Min / Max Current
@FLOWSTAT(6:24::1)@ @FLOW(6:last:1)@
@FLOWSTAT(5:24::1)@ @FLOW(5:last:1)@
@FLOWSTAT(8:24::1)@ @FLOW(8:last:1)@
@FLOWSTAT(9:24::1)@ @FLOW(9:last:1)@
@FLOWSTAT(10:24::1)@ @FLOW(10:last:1)@
Admit: @FLOW(14:first:1)@ @FLOW(14:last:1)@ @BMI@
LAST VS:
@VS@
DRIPS & MEDS
Scheduled Meds
@MEDSSCHEDULED@
Home Meds
@MEDSSIMPLE@
DRIPS & CONTINUOUS IV’s
@CONTINUOUSMEDS@
LINES:
PIVs
•
IMAGING
@IMAGERESULTS48H@
@IMAGING@
NURSING PLAN
Universal fall precautions are in place:
Orientation of the patient to the environment.
Explanation of call light and patient demonstration of call light use.
Call light attached to bedrail and within reach.
Gurney low, brakes locked, and both side rails up.
Patient’s personal possessions placed within safe reach on bedside table.
Adequate room lighting provided for patient to locate call bell.
Environment uncluttered.
Sitter at the bedside. Purewick in place when in indicated
4 Eyed Skin check done w/2nd RN verification.
In addition to the universal precautions:
A fall risk sign has been placed at the door of this patient’s room and a fall risk band applied to the patient.
A contact/droplet sign has been placed should it be indicated (see chart).
Report given to oncoming RN noted above at transfer, who then assumed all care.
Howie Realubit, BSN, RN, CCRN
Electronic Signature
@TD@ @NOW@