The Basics
Where is one spot where you can quickly determine if your admission documentation is complete?
On the brain! In the flowsheets!
Under what tab do you fill out the learning assessment?
Education tab!
What do you type into the search bar in order to get to the admission documentation flowsheet?
"screenings"
When doing your admission screening, what do you do when your patient states they do not feel safe at home?
Notify a provider!
What admission documentation must be done within the first 4 hours of admission?
Columbia Suicide Screening, height, Pain assessment, travel and exposure screening, systems assessment, RASS, CPAP/BiPAP at home
Your patient has medications that they take daily with them- what will you do?
Send medications home with family or secure medications in the M2B cabinet and document in the flowsheets what is secured.
What admission documentation must be done within the first 24 hours of admission?
ADL, Advance directive, alcohol screening, broset assessment, care plan (goal), Communication needs, Discharge plan. drug screen, fall assessment, EDUCATION, LDA avatar, smoking hx
Your patient is intubated and sedated- do you need to complete a learning assessment?
YES! Regardless this must be done within the first 24 hours of admission. You will make a comment that the patient is unable to participate d/t medical condition or AMS.
For the ADL screening- is it based on the patients baseline or the patients current condition?
Based on the patients baseline
What are the steps of a bedside swallow study
1. Before anything assess your patient, are they coughing
2. 3 mL of water by spoon
3. 100 mL of water by cup
4. One club cracker