MedSurg and ICU Nursing Admission Process: SurgicalAdmit

Version 2 6/26/2013

PAT or SDC Nurse

  • Enters Home Meds, Allergies, Height/Weight
  • Prints Home Medications for the Surgeon

Hand Off

  • PACU RN calls Inpatient RN for verbal hand off
  • Reviews PAT/OR/PACU Paper Documentation

Inpatient Nurse

(Upon Patient’s Arrival to the Inpatient Unit)

Process Transfer Orders via Status Board:

  • Click [Lists]
  • Find by either [Find Account] or [Find Patient by Inpatient Location]
  • Click the [Add to my List] footer button
  • Click the [Transfer] flag within the PCS Status Board under the Orders column
  • Click the [Manage Transfer] footer button
  • Click the [Process Transfer] footer button
  • Click [Yes] to process the transfer orders

Document Arrival to Unit:

  • Click [Worklist]
  • Documents Arrival to Unit – Admit/Transfer Assessment

Review Home Meds, Allergies, Height/Weight:

  • Launch [Open Chart]
  • Click [Clinical Data]
  • Click on the [Home Meds]tab
  • Confirm Prior Entries (Last adm)
  • Enter New Meds
  • Edit/Delete Inaccurate
  • Click on the [Allergies] tab
  • Review any current Allergies or add any additional Allergies
  • Click on the [Main] tab
  • Review Height and Weight

Add MedSurg Plan of Care:

  • Click [Plan of Care]
  • Click the [Add] footer button
  • Select [M/S/ICU-Plan of Care]
  • Save

Admission Documentation (Worklist):

  • Admission Assessment
  • Past Medical History
  • Fall/Risk/Safety Assessment
  • Braden/Skin Risk Assessment
  • Vital Signs
  • Physical Assessments (ADM)
  • Cardiovascular
  • Respiratory
  • GI
  • GU
  • Skin
  • Neuromuscular
  • MS Psychosocial Coping

Individualize the Plan of Care:

  • Document: Individualized Focus of Care Intervention
  • Select appropriate Problems to add to the patient’s Plan of Care
  • Checkmark the suggested Problems
  • Select [Add to Care Plan M/S/ICU-Plan of Care]
  • Actions for the suggested Problems will update to green text
  • Click [OK] to save the Problems to the Plan of Care

Further Customize:

  • Edit the Frequencies based on the protocol per unit and the patient’s status
  • Edit the Frequency on the worklist by clicking directly on the current Frequency and editing the text
  • Indicate the Disease Process that each Problem relates toand the specific Goals which will be set to achieve that Outcome
  • Click [Plan of Care]
  • Click within the [Item Detail] column for the Problem or Outcome
  • Click [Edit] within the text box
  • Click [Save]

Order Management - Nursing Process

  • Acknowledge orders (Status Board)
  • Discrepancies should be called to Pharmacy
  • Administer Medications (MAR)
  • Scan Patient’s Wristband
  • Scan Medications

Version 2 6/26/2013