GRA ICU Collection Guide: Difference between revisions
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*When patients are discharged the green sheets are placed in the front of the TISS/Green sheet binder. | *When patients are discharged the green sheets are placed in the front of the TISS/Green sheet binder. | ||
*Thinned charts and old charts are kept on the lower shelf of the rounds cart. | *Thinned charts and old charts are kept on the lower shelf of the rounds cart. | ||
*The patient's chart is kept | *The patient's chart is usually kept on a bedside table with the bedside red binder | ||
== Documentation change once Transfer Ready == | == Documentation change once Transfer Ready == | ||
Revision as of 11:54, 2017 February 15
This page contains information specific to Grace Hospital ICU collection only. See GRA General Collection Guide for information related to all Grace Hospital collection, and see ICU Curriculum for information to all-site ICU data collection.
computer #GHDW210X5100R23
ICU ATD log
See also Identifying ICU admissions
Grace MICU does not use the standard Admission/Transfer/Discharge Log. Admissions/Discharges are logged into a Ledger book located to the side of the Ward Clerk's desk. Admit from location, patient name, age (not DOB), admit/transfer/discharge date and time, and MRN are manually entered into the ledger. This ledger is used to keep track of in-house Code Blues, ventilator hours etc.. At the start of a new month, all patients still admitted in the ICU are carried forward in the ledger. Their names, date of admission, MRN, etc. are re-entered on the top of the first page of this new month. Carried over entries are assigned a letter in alphabetical order ( A., B., C, etc.). All new admissons are assigned a number, starting at one (1) for the first admission of each month.
- all admissions/transfers/discharges are also noted in the calendar notepad at the clerk's desk
Charts, TISS and Green Sheets
TISS sheets are kept on the nurses' bedside clipboard. When the pt is discharged or when the TISS sheet is full it is placed in the front of the "TISS/Green sheet binder" located on the rounds cart.
- When patients are discharged the green sheets are placed in the front of the TISS/Green sheet binder.
- Thinned charts and old charts are kept on the lower shelf of the rounds cart.
- The patient's chart is usually kept on a bedside table with the bedside red binder
Documentation change once Transfer Ready
Once the patient has been deemed medically stable ie. transfer ready, the ICU flowsheets are no longer used. Only the daily systems review sheet is used to document VS, activity, lines etc.
Medications
Continuous flow medications are documented on both the ICU flowsheet and the MAR. PRN medications are documented on the PRN (non-scheduled) medication form. Regularly scheduled medications are documented on the scheduled medication form. Blood products are documented on the Blood product form, the ICU flowsheet or sometimes on the scheduled medication form if ordered regularly ie. HSA25% BID