acute care EMR and planning

pt identifiers and demographics

name, DOB, MRN, contact info, gender, pronouns, preferred name, ethnicity/race, language, photo

admission note (H&P)

hx present illness, PMH, PSH, family hx, personal/social hx, physical exam with ROS, lab and diagnostics, assessment, POC

provider notes

daily, consults, progress in chronological order

precautions and directives

allergies, isolation, medical, code status, safety

problem list

new, current, chronic dx impacting care

results

labs, dx tests/procedures, imaging

orders

electronic and verbal instructions from LIP

vital signs

BP, pulse rate, RR, temp, SpO2, weight, pain

medications

reconciliation of prior and new

pt specific orders

activity: bedrest, HOB, OOB, WB, mobilize as tolerated
surgical: sternal, arthroplasty, spine, abdominal, plastics/reconstructive, craniotomy
equipment: DME, orthotics, specialty surface, LDA
medical: dietary, fluid restriction, vitals, seizures, aspiration, falls, isolation

using chart review info

determine appropriateness of PT (potential for medical instability/unpredictability) - communicate to LIP when PT not indicated
prediction of pt presentation, develop gameplan

patient informed consent

be intentional, intro self and role, confirm pt identity, educate on role of PT, determine relationships of people present and ask if ok to proceed with them present

prep and environ setup

anticipate and perform actions necessary to ensure pt privacy, perform proper hand hygiene and follow infection control, facilitate environ that ensures pt safety

AM-PAC 6 clicks

requires license to purchase, highest score 24 lowest 6
a lot: mod-max assist, a little: min-CGA
turning over in bed, STS, moving from lying to sitting EOB, moving to and from bed to chair, walking in room, climbing steps (can infer score)

DEMMI

free, used internationally
15 skills that range from easy to more specialized/high level skills

gait speed

recommended is 4m but can do longer

JH-HLM

interprofessional mobility scale, any unit, free
1-8 highest level of mobility achieved in a shift/day, often scored by nursing
does not include assist level needed

IMS

ICU specific, 0-10 scale highest level of mobility achieved in a day

supplemental outcome measures

6MWT, 30 STS, SPPB, TUG
gives options to support clinical decision making or address specific pt goals