history, note taking, and transitions of care

Tobacco:Alcohol:Illicit drugs:Occupation:Living situation:Sexual history (if relevant):

key features of a social history

[Name], [Age/Sex] with [major diagnosis] presenting with [summary of HPI]. Leading diagnosis is ___. Differential includes: ___, ___, ___.

what is the template to writing an intake assessment?

Overnight events:

Patient reports:

Pain:

Intake/Output:

Diet tolerance:

Bowel/urine:

components of a daily progress note (subjective portion)

- Problem 1-

Problem 2

- Chronic conditions

- Fluids

- Nutrition

- Prophylaxis

- Disposition

template of writing plan in a progress note

ADC VANDISMAL

Admit to floor

Diagnosis

Condition: stable/fair/guarded/critical

Vital frequency

Activity

Nursing

Diet

IV fluid (type and rate)

Symptom medications

Medications

Allergies

Labs

admit orders

I/Os, weights, wound care, neuro checks, telemetry, glucose checks, Foley care

examples of nursing orders

-medication errors

-communication failures

-lost info/diagnostic delays

-gragmentation of care and confusion

-safety risks after d/c

-SDOH

what are the primary hazards in transitions of care (ED → inpatient → ICU → floor → rehab → home)

The planned next step or location for the patient after the current phase of care.

define disposition in the medical setting

Med-Surg

Patients are stable but need hospitalization—NOT critically ill; Admit to

Med-surg

where to admit?

Pneumonia on oxygen (non-high flow)

Cellulitis needing IV antibiotics

Uncontrolled diabetes

Post-op day 1-2 routine recovery

Heart failure requiring IV diuresis (stable vitals)

Vital signs q4h, routine labs

typical monitoring on med-surg floor

med-surg plust continuous cardiac monitoring

define telemetry level of care

telemetry

what floor to admit to?

Chest pain

Arrhythmias

Heart failure patients at risk for dysrhythmia

Electrolyte abnormalities (e.g., K+ 2.8)

Overdose or withdrawal patients needing monitoring

tele

which has more freuqent nursing checks, med-surg or tele?

step-down unit

where to admit?

High-flow oxygen (HFNC)

Noninvasive ventilation (BiPAP/CPAP)

Sepsis requiring closer monitoring but not pressors

Post-op patients at higher risk

Patients needing q2h neuro checks

ICU

what floor to admit to?

Shock requiring vasopressors

Need for mechanical ventilation

ARDS

DKA with severe acidosis

Massive GI bleed

Post cardiac arrest

Severe trauma

Continuous cardiac

Continuous pulse ox

Arterial lines, central lines

1:1 or 1:2 nurse staffing

typical monitoring on an ICU floor

PACU

high-acuity monitoring immediately post-op

PACU

what floor to admit to?

Immediately post-anesthesia

Patients needing pain control or airway monitoring

medication reconciliation performed at every transition

most important strategy to mitigate hazards of transitions of care

SBAR

consistent, clear, structured, and easy-to-use method of communication between health care personnel; it organizes communication by the categories of: Situation, Background, Assessment, and Recommendations.

Illness severity

Patient summary

Action list

Situation awareness & contingency planning

Synthesis by receiver

components of I-PASS standardized hand off tool

-accurate and reconciled medication list

-follow up plant

-pt education and teach-back

-assessment of pt's ability to self-care

-ensure access to necessary equipment and services

-summary document sent to outpt providers

6 components of a safe discharge plan

Hospital course

Med list

Pending tests

Follow-up needs

Recent imaging/labs

what should be included in a summary document sent to outpt providers

Safe at home but needs periodic help

Post-op patients

Elderly with mild functional limitations

indications to send home with home/health

Stroke

Major trauma

Severe deconditioning

Post-op spine/orthopedic surgery

inications to d/c to acute rehab unit

acute rehabilitation unit

focuses on high intensity therapy

≥3 hours/day PT/OT/Speec

24-hour nursing

Low-intensity PT/OT

IV antibiotics

Wound care

Tube feeds

care associated with a skilled nursing facility

Medically stable but can't go home

Needs rehab but cannot tolerate ARU therapy schedule

indications for d/c to a skilled nursing facility

Ventilator weaning

Chronic wounds

Long-term IV meds (e.g., osteomyelitis)

indications for long term acute care hospital