Admission Charting
This must be documented with each admission and is why they came to the hospital.
What is Chief Complaint?
How often summary charting of the FHR and UC takes place.
What is 30 minutes?
This should be documented on moms when vital signs are done and PRN.
What is fundal height and lochia amount?
This is how often vital signs should be taken while in PACU.
What is Q15 x2 hrs?
The frequency of which an IV with continuous fluids/medications running must be assessed and documented on.
What is every 2 hours?
This has to be documented completely to include mode and year.
What is Gravida and Para?
This should be documented on admission and pre-birth.
What is the hemorrhage risk assessment?
These assist with circulation and should be documented on Q4 hrs. while in use.
What are SCD's?
This should be printed and placed on each post-op PACU patient's chart.
What is an EKG strip?
This must be documented on prior to any invasive procedure such as C-section, Epidural, or Circumcision.
What is the Pre-procedure checklist?
This must be completed and documented within 60 minutes from arrival.
What is Comprehensive Head to Toe assessment?
This is how often vital signs should be assessed while on magnesium.
What is prior to infusion, Q15 x1 hr, then Q30 min x1 hr, then Q1 hr until discontinued.
For a post-op CS patient, this should be included and charted on when vital signs are taken.
What is incision assessment.
This is documented under CS equipment and must be documented for each C-section.
What is SCD pumps?
These must be charted anytime there is a change in patient status, a change in the plan of care, and as needed.
What are nurses' notes?
We need to document the name and location of this for every patient with each admission.
What is patient pharmacy.
This must be documented prior to starting the infusion, Q30 minutes while infusion is running, and prior to restarting the infusion if it is stopped.
What is the Oxytocin Checklist.
This is how often education, fall risk, braden assessment, intake and output, isolation, and tubes and drains should be documented.
What is Q 12 hrs and PRN?
This vital sign must be taken and documented upon admission to the PACU and prior to discharge from the PACU.
What is temperature?
This is the timeframe for pain reassessment for IV pain medicine.
What is 30 minutes?
These questions help identify potential needs the patient might have. Asking these questions on admissions helps assure the patient is able to get the resources they need prior to discharge.
What are Social Determinants of Health questionnaire?
This documentation should take place prior to taking a patient to the operating room for a cesarean section.
What is the preprocedure checklist?
This should be documented with every set of newborn vital signs.
What is newborn assessment pain?
This C-section specific charting must be completed in PACU when VS are taken.
What is incision assessment?
This review must take place with every change of shift and transfer of care.
Bonus: what 3 main things should it include?
What is a chart check that includes the MAR, orders, and results review?