Report Sheet for General Medsurg/Tele
3) Code Status
5) Primary Physician and or Teams involved
6) Chief Complaint and Diagnosis
7) *Pertinent* Medical Hx
8) Isolation for Contact, Droplet, etc.
Extremely brief, succint narrative of course of day: ("Patient's major issue today was increasing respiratory failure as AEB tachypnea, desats, increased 02 needs. We did a CXR, found her lungs to be wet, gave her 20mg of lasix X1, put her on biPAP and gave her albuterol tx with increased 02 sats, gave.5 ativan IVP for anxiety with good effect. Decreased tachypnea post intervention, but she is still on close resp. watch.")
*Focused* Review of Systems (Often contains narrative components). (Not all of these will apply to all situations--feel free to add or subtract given your specialty).
Neuro: Mental status, orientation. BUE grips/strength, BLE plantar/dorsiflexion. Any hemiparesis or gait issues? Need for assistive devices for ambulation or hearing, sight? Any acute mental status deviation from baseline. Time and dosage of last pain meds if given. Restrained? If so, when is the order expiring?
Cardiac: Temp and source (oral, axillary, core, rectal, etc). Rate, rhythm, arrhythmias, heart sounds, peripheral edema, peripheral pulses, pertinent labs (K, Ca, Mg, Bun/Cr). Repletion of electrolytes if done.
Respiratory: RR, adventitious sounds, O2 therapy if any, 02 sats on same. Resp. therapy tx's and time of last tx.
GI/GU: Abd inspection, bowel sounds, NPO or diet status; swallow status; aspiration precautions. Any n/v/d? If so, how treated? Dentures if any. OGT if placed. If tube feed, is it by OG/NGT? Formula, rate, H20 flushes, residuals if any.
GU: color, appearance, any odor. Foley or other indwelling device. Void amt per hour or shift. If HD patient, HD schedule, last HD date, plans for further HD, whether or not patient is anuric. AVF's, which arm if present.
Skin: Gen assessment, abnormal findings, dsg changes.
Psych/social: Family, SW issues.
Labs values (esp if abnormal).
Test Results/Pending Results
type and rate
Timing of any pertinent med given or due.
Plan of care:
1)Go over shift orders together!
2) What is/are the *immediate* primary need(s)/intervention(s) for this patient, by priority? (ex: draw PTT for heparin titration @ 0800, preop checklist needs to be completed, pending procedure teaching).
3) General trajectory of care: What are we hoping to accomplish/which systems need closest monitoring (ex: resp. watch for desats and increased O2 needs, pulmonary toilet, etc, V/Q scan for PE).
4) Ask: "Any questions?"