Vitals/Monitoring
Vitals every 5-15 minutes until stable, then hourly.
What are vital requirements for patients with an ESI level 1 or 2?
This should be documented when updating or notifying the provider of changes in patient condition, abnormal vital signs, or critical lab values.
What is provider communication?
Should be documented on every patient to address airway, breathing, circulation, and disability.
What is a primary assessment?
Vitals within one hour.
What must be completed prior to discharge?
777
What is the phone number to call with an alert?
Vitals every 2 hours and PRN per nursing judgement.
How often are vitals required on ESI level 3 patients?
This should be completed as soon as you are aware of patient admission and updated regularly if patient is boarding.
When is IPASS completed?
A focused assessment by body system that relates to patient's chief complaint and is required to be documented on all patients.
These patients require vitals within 30 mins of disposition.
What is vital requirement for critical care patient transfers?
We must screen every patient for this starting at age 12.
What is the Suicide Screening requirement?
Vitals should be obtained at a minimum of every 15 minutes and PRN.
How often are vitals required on patients with vasoactive infusions?
This must be documented within one hour of administering medication.
What is the documentation requirement of a pain assessment?
Is documented as needed with any change in patients condition and following any intervention.
What is the requirement of a reassessment?
This must be completed prior to transferring a patient to an outside facility.
What is EMTALA?
This order is only good for 4 hours and must be ordered by a physician.
What is a violent restraint order limit?
Vitals should be obtained on arrival, at discharge, and PRN.
What are the vital sign requirements for patients assigned an ESI level 4 or 5?
Should be documented hourly to show that you have checked on the patient and addressed their needs.
What is intentional rounding?
A reassessment should be documented every 2 hours on these patients.
What is required documentation of a critical care patient?
This should be documented on all patients as a double check to ensure all documentation is complete and patient is being charged for care they received.
What is Doc Verification/ Charge Capture?
Psychosocial assessment, Columbia Suicide Screening, and suicide interventions including sitter
What 3 things need to be documented every 12 hours on suicidal patients?
Vitals are required at least every 8 hours or per order.
What are vital requirements for med/surg inpatient boarders?
A helpful tool, found in flowsheets, to utilize in documentation of neuro assessments or restraints.
What is copy forward?
This cannot be charted by exception.
What is the documentation requirement of a neurological assessment for stroke patients?
If the patient received this, they must be monitored for 15 minutes prior to discharge.
What is required care of patient after administering tetanus shot or IV/IM narcotic pain medication?
When an order is placed, this assessment should be completed and documented every hour x4, then every 4 hours, until a score of < 8 is reached for 24 hours.
What are requirements of CIWA?