15 minutes
This must be verified before administering any medications on admission.
What are patient identifiers and allergies?
Where do you find your Admission & Discharge requirements for Charting?
Sidebar Summary
Completing this prevents duplicate or missed home medications?
Medication Reconcilition
Where do we document how patients transfer?
Patient whiteboard as well shows up on their storyboard after completing the safe handling record
The minimum discharge teaching that must be completed even at 02:00.
Medications, follow-up plans, and reasons to return to care
This assessment establishes baseline safety risk and guides precautions.
What is a fall risk assessment?
How long do you have to complete all of the Admission Documentation?
24 hours
How often are you completing the Braden Score?
On admission and every MWF when score is 18 or less
What Documentation is required when a pressure injury is present on admission?
Place on Avatar as a wound so that it is noted it was not developed in Hospital
Side note- if found in hospital an RLS must be submitted
This documentation step protects patient safety and supports day-shift follow-up after a night admission.
Clearly identifying incomplete admission tasks in the chart (care plan summary)and handover
This establishes baseline physiologic status on admission
What are baseline vital signs?
What are two examples of documentation that could be removed from the Avatar on discharge?
IV, Wound, Foley,
What are two safety Interventions when patients are identified as a falls risk?
Non-Slip Socks, Bed alarm, Signage
What do we do with patient belongings that are not able to be given to caregivers or sent home?
Document all belongings that stay with patient in hospital within 24 hours of admission
This step helps prevent duplicate dosing when a patient arrives from the ED late at night.
Confirming medications already given and their administration times.
*question daily medications that show up in the MAR overnight
What information must be clarified immediately if missing on transfer.
Allergies
GOC
Diagnosis
Reason for transfer
Infection status
Where do we fill out the last doses of medication we have given at the time of discharge?
Discharge instructions-Medication detail-Medication List
At discharge what information Can we go over to prevent falls at home?
Fall Prevention Strategies
Name two common education topics that could be discussed at discharge
Medication changes, Follow-up appointments, wound care Instructions, Red Flags, when to seek care (S&S of infection)
The minimum infection prevention step required when a patient arrives overnight with an unknown communicable disease status.
Completing admission screening questions and applying standard precautions
Often delayed but critical to prevent early harm.
What is the BRADEN Score (Skin and pressure risk assessment)
What are 3 Required Documentation requirements within 4 hours on admission ? (Bonus $100 if you get all 5)
ARO
Allergies
Weight and Height
CD Screen
Vitals including pain
This service supports safe transition home of elderly or high needs patients often living at home alone
Home Care (transition services)
True or False All patients admitted on acute care need a documented Code Status? Where would we see the status?
True
Story Board/Care plan/Patient lists under GCD
White Board in Patient rooms
A patient admitted overnight who is confused, has IV lines, and requires frequent toileting should automatically trigger this.
Enhanced safety and fall-prevention interventions