All New Admissions (For Or, Direct, Walk-in, Trans-out)
CALL INFORMATION #0 TO OPEN ROOM DOOR
Instruct housekeeping to clean the room
Instruct NAs to prepare and charge the following:
o Interfolded linen
o 20 pcs gloves
o Pillow
o 3 surgical masks
New Admission (ie. those coming from ER or For OR)
Prepare the chart clipboard with the room number and patient’s name (color coded)
Prepare the chart with the following forms:
o Professional Fee Form
o Patient Chart Checklist
o Patient Allergy Profile
o Nutrition Risk Screening
o Fall Risk Screening
o Standing Order Sheet
o Medication Record
o Vital Sign Monitoring Sheet
o Graphic Sign Sheet
o Doctor’s Order Sheet
o Admitting Form
o Laboratory Flow Sheet
o Intravenous Fluid Administration Record
o Hourly Intake and Output
o Nurses Notes
Create a Viber group with the following persons:
o Main Attending Physician
o Hospitalist on duty (IM, OB, Pedia, etc)
o IF for OR, Anesthesiologist (sometimes indicated in Doctor’s order or “on deck”)
And, include the following details in the message:
o Room #
o Patient’s name
o Latest VS
IF for OR, add the following forms:
o SURGICAL BILLING CLEARANCE
Call OR for operation cost and write amount in the form with pencil
Give to relative and instruct them to go to billing and come back with signature
o PRE-OP CHECKLIST
o ANESTHESIA CONSENT
To be signed by relative or patient
o SURGICAL TREATMENT CONSENT
To be signed by relative or patient
If for OR or as ordered, prepare for IV insertion as instructed or before NPO status,
usually D5NR (check doctor’s order)
o Charge the following and get it from CSR:
IV Starter Kit
Supercath needle (needle gauge depends)
Heplock
IVF (if any)
Check for pre-op doctor’s order (or to follow)
IF given via Viber, write it in doctor’s order sheet – include doctor’s name then sign (RN)
IF for OR, call OR for schedule (schedule is given by doctor)
Check ordered meds and create medicine cards
You can charge or ask medicating nurse
Get old laboratory results and patient’s meds from patient and add to chart
Create or update Kardex accordingly
Note:
Some patients (ie. those coming from ICU or Area 19) already have Viber GC’s, so simply request
to be added in the GC upon endorsement.
Usually, these patients will already have medicine cards, simply update as necessary or continue
by placing the medicine cards on the medicine board.
Referrals
All referrals, such as cardiopulmonary clearance
o Write details in doctor’s order sheet (name of doctor and referral purpose ie. CP
clearance) and have patient or relative sign it in the chart
Note that all For OR patients need CP Clearance, including
colonoscopy/endoscopy
o Send private message to hospitalist to facilitate referral
o Add the referral (referred doctor’s name) in the system
IF patient is using HMO, call HMO #3006 to check if the referred doctor is covered
Call ER to check schedule of available hospitalist (ie. Pedia, IM, etc)
Note:
Private case – Can choose their co-management doctors
Walk-ins – Can not choose their co-management doctors
Laboratory and Diagnostics Order
Encode or charge and note the time (AM or PM) and the doctor who ordered
Once official results are available, take a photo and send it in the Viber group of the
patient
Give copy to the patient
To know if labs are done, always verify during endorsements; if not yet done, always
check if encoded already
Note:
Write the following with pencil on the doctor’s order sheet as appropriate:
(+E) – positive encode; the laboratory test was already charged in the system
(-E) – negative encode; the laboratory test was not yet charged in the system
(-OR) – negative official result; the laboratory test was done but still waiting for official result
(+OR) – positive official result; the laboratory test was done and official result is available
Nurses Notes
Must be done for all patients chart (Focus-Data-Action-Response) see sample below
24-Hour check
PM Nurses must check if all orders are carried out
Put a red line at the end of PM shift and sign
Always take note of special endorsements, such as:
NPO status and time
Pre-op instructions and meds
CBG monitoring times
Arm precautions
IVF type and duration
