Admissions

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Below is an adaptation of my workflow for admissions. Do what works for you. This style will probably be less popular among ED staff. Beware of anchor bias as well.

Using Notewriter

  1. Avoid using others' templates until EPIC becomes familiar. Use the admission H&P template note writer
  2. This is located under: Admission → H&P Notes → Create Note in NoteWriter.
  3. This enables use of macros for ROS and Exam.

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Chart Review

  1. If possible, write your note while doing chart review. This is important for reviewing key information including vitals, labs, micro, studies, imaging.
  2. EKG is usually not available in EPIC at time of admission. Ask around and track it down in the ED. Make a copy.
  3. It is a good idea to check the most recent discharge summary and any recent encounters.
  4. Checking the MAR is useful since it tells you what has already been done.
  5. Go into Chart review > Encounters. There will be a pink timeline of events in the order they occurred in the ED.
  6. Be aware of the possibility of anchor bias when performing a thorough chart review.
  7. When ready to use templates, use the template to auto-populate more data than needed so time is not wasted tracking it down. Delete useless or outdated info.

Using Macros

  1. Macros are accessed by clicking one of the buttons or tabs above the active note.
  2. Macros can help improve speed and efficiency. Just don't get lost in the details.
  3. Document macros in the room or right after leaving the room.

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Medication Reconciliation

  1. Try to do medication reconciliation in the room.
  2. Found under Home Meds OR Admission > Order reconciliation > Pages 2 and 3
  3. There are many medications that the hospital does not carry. Clarify if patients mind taking an alternate medication.
  4. Uncommon medications can be added
  5. Discontinue medications the patient is no longer taking. This still requires clicking "Do Not Order" on the next screen.
  6. No. The patient probably does not need that rare specific vitamin that the hospital does not carry.

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Updating the Problem List

  1. Often, the patient will come from the ED with an inaccurate or incomplete problem list.
  2. For now, choose a primary problem for the admission.
  3. Use the Problem List Guide to complete the problem list before signing your note.

Admission Orders

  1. Remember, admission orders are the time limiting factor for getting patients to the floor.
  2. Orders can often be added to the ED lab tubes. Many orders are better performed in the ED, including urgent imaging studies.
  3. If the patient has severe sepsis, add the sepsis order set. Verify time-sensitive orders.
  4. Use the general adult admission order set for most patients.
  5. Admission location is usually decided for you, unless the patient is a transfer patient.
  6. Verify the patient's Code Status.
  7. Decide if the patient needs Telemetry.
  8. Decide on frequency of vitals.
  9. Few patients need continuous pulse oximetry.
  10. Every patient needs a diet order, even if NPO.
  11. Every patient needs DVT prophylaxis, if not lovenox or heparin, then SCDs. Uncheck the risk assessment module.
  12. If the patient needs oxygen, use O2 therapy per protocol.
  13. Decide if the patient needs IV fluids.
  14. Decide on follow-up labs and morning labs.
  15. Use the adult insulin order set for every diabetic. In general, oral medications should be held.
  16. Order basic PRN pain meds. Almost every patient can have tylenol. Not every patient needs IV opioids.
  17. Order comfort PRN meds, including bowel regimen and antiemetics.
  18. Most patients do not need PRN benzos or benadryl by default.
  19. Nursing doesn’t like it when orders come in piecemeal, but you don’t have to order everything now.
  20. If in a bind, then ED Transition order set puts in a diet and vitals and will move the patient to the floor.

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Review and Sign Orders

  1. If the patient is admitted for observation, then lab and procedural orders will require an associated diagnosis.
  2. Click "Dx association," and it will pull up a table. Clicking the top row labelled "primary problem" will put a diamond under the primary problem
  3. Clicking the text of the problem in this table will select all your orders and associate it with that dx. There is no need to go through 40 orders and choose the exact problem for each order.
  4. REALLY IMPORTANT, click "Sign will be initiated by receiving unit." This puts your orders into holding for release by the floor nurse.
  5. You will get many errors warning you that you are a bad doctor and that there’s all sorts of bad things that will possibly happen for the orders you just placed. Review these and then scroll to the bottom and click “Clinician Reviewed.” Actually, clicking any of the buttons works.
  6. CONGRATULATIONS, orders are in. The patient has been admitted.
  7. Don't celebrate too long, there is still a note to finish, and the patient probably needs to be staffed.

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