Documentation Counts!
These 3 elements are required for each entry in the patient medical record.
1.Time 2. Date 3. Signature
This is the required information to confirm correct patient identity, to prevent wrong-patient events.
What is: Name and DOB or Name and MR#?
This process of comparing patient medication lists at each transition of care has been shown to significantly reduce medication-related adverse events.
What is Medication Reconciliation?
All patients admitted to the hospital must have this completed by a provider within 24H of admission.
What is the History and Physical?
This is where to find a fire extinguisher in the hospital.
Fire extinguishers are located at exit doors.
This safety precaution is required any time a medication is transferred from its original container, such as drawn into a syringe. This includes during surgeries/procedures, if medication is not administered immediately.
What is label the syringe/container with medication name, strength, and amount (if not marked on container.)
These types of orders are only permitted during a procedure/surgery or during an emergency.
What are verbal orders.
These are the steps to take during a fire.
What is RACE?
1. Rescue- remove patients from fire proximity
2. Alarm - pull file alarm AND dial 444 (in hospital) Call 911 at off-sites.
3. Confine the fire- close doors
4. Extinguish the fire or Evacuate the area
These items must be read aloud to the ordering provider who is offsite and giving a telephone order.
What are: all warnings and pop-ups
This is the timeframe required to write a post operative note.
A post operative note must be completed before the patient leaves the procedure room. If a full note cannot be written/transcribed, an abbreviated note containing the following must accompany the patient to the next level of care:
1. Estimated blood loss (specify if none)
2. Any specimen(s) removed (specify if none)
3. The postoperative diagnosis
4. Name of surgeon/proceduralist
5.Their assistant(s) if any
6. The name of the procedure performed
7. A description of the procedure
8. Findings of the procedure
f care:
This is the timeframe required for face to face provider evaluation if a patient is placed in restraints for violent/self destructive behavior.
What is within one hour?
These are the required elements of a medication order.
What is: medication orders must include:
1. drug name
2. dose
3. strength
4. quantity or duration
5. route of administration
6. frequency of administration
7. indication if PRN
8. time and date or order with provider signature (automatic with CPOE)
These are 3 elements required to appear in the post operative note.
6. The operative or other high-risk procedure report includes the following information:
1. Estimated blood loss (specify if none)
2. Any specimen(s) removed (specify if none)
3. The postoperative diagnosis
4. Name of surgeon/proceduralist
5.Their assistant(s) if any
6. The name of the procedure performed
7. A description of the procedure
8. Findings of the procedure
These are the people required to participate in a Time-Out and the required action of each person.
What is- All parties present in the procedure room?
STOP ALL ACTIVITY and actively engage in the team-centered process of the Time-Out.
If activity is resumed during the Time-Out, the Time-Out must be stopped until the distraction has concluded. The Universal Protocol Time-Out must then be re-initiated from the beginning of the process.
These are the required elements of a titration order.
a. intent of the order. (i.e. “titrate medication to achieve blood pressure of ___/___”),
b. initial infusion rate
c. how often rate/dose can change
d. max & min dose/rate
e. titration increments clearly defined so staff know how much to increase or decrease