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ADMISSION CHECKLIST
ADMISSION CHECKLIST
⬜ Place admission orders
⬜ Update, reconcile and order home medications
⬜ Ensure next labs/investigations are ordered if needed
⬜ 'Best practice' orders
E.g. VTEp; glucose monitoring +/- insulin sliding scale; PRNs for pain, nausea, constipation and nicotine replacement - this will save patients from discomfort and your colleagues from unnecessary pages.
Review referrals to allied health - your patient may not need PT/OT/SW if they are bedbound at LTC.
⬜ Complete & route admission note to the patient’s family doctor and relevant specialists
They will want to be informed or may even be involved if around/on service!
⬜ Assign patient to their team list
⬜ Update handover text
⬜ Present case to your senior/MRP
· Place admission orders
· Place admission orders
Orders > use General Internal Medicine Admission order set (type gim as an order to find this)
Fill the Admit to Inpatient order: service (General Internal Medicine), diagnosis, admitting physician, provider care team
Complete the rest of the order set: COVID-19 risk, code status, ancillary consults, diet, activity, labs, imaging, IV fluids, DVT prophylaxis
Sign when done
Read the next section for Home Medications
· Update, reconcile and order home medications
· Update, reconcile and order home medications
Confirm and update home medications
In the Admission tab, select Admission Orders
This leads to the Review Home Medications screen where you can view and update home medications.
Confirm medications by: patient/caregiver's report, blister packs, ODB lists on ClinicalConnect, and/or faxed lists from their pharmacy
⚠️ Do not simply reorder all home meds on Dovetale without ensuring these are up-to-date.
For a patient being admitted from ER, what is recorded as home meds is usually outdated from a previous admission. You must order the correct home meds upon admission, to be later confirmed by pharmacy.
Decide which home medications should be continued, changed or stopped
Select 2. Reconcile Home Medications
Order/don't order/replace/remove each home med
· Assign a patient to a team list
· Assign a patient to a team list
In Patient Lists, right click the patient’s name > select Assign Teams and search for the team name
· Transfer to ALC (Transfer order)
· Transfer to ALC (Transfer order)
Transfer tab > Transfer Orders
Fill in the Transfer to new unit order - service (General Internal Medicine), future attending provider (usually one of Dr. Moreno, Dr. Alton or Dr. Mallah - confirm with charge nurse)
Determine which current inpatient orders should be continued (usually most) or modified
Sign transfer orders when done
Write a transfer note (note type: progress note)
May need: COVID swab, courtesy handover call to next MRP
· Transfer to Complex Care or Rehab (Discharge & Readmit order)
· Transfer to Complex Care or Rehab (Discharge & Readmit order)
Discharge tab > select Discharge Readmit at the top > Discharge Readmit Orders
Fill in the Discharge/Readmit Order - service (General Internal Medicine), new class (CC or rehab), future attending provider (usually an internist)
Determine which current inpatient orders should be continued (usually most) or modified
Sign transfer orders when done
Write a discharge summary
May need: COVID swab, courtesy handover call to next MRP
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