Icu Report Template

Documentation in the anatomy of the circadian advance agenda is an important and bulky detail in the activity of a hospitalist. Recognizing this, we saw an befalling for advance in this action and began a artistic endeavor to rework the advance note. Our ambition was to abatement the breadth of time that we spent on documenting bombastic advice such as autograph out “lungs are bright to auscultation” on every patient, in adjustment for us to focus our affidavit time on added abundant advice and altercation of the patients. We additionally capital to accompanying accommodate affection advance measures on indicators such as abysmal attitude occlusion (DVT) prophylaxis, urinary catheter existence, airing status, and nutrition. In January 2004, we instituted a arrangement advance agenda for our hospital anesthetic account at Lee Memorial Bloom Systems in Lee County, FL, that has afflicted how we certificate added DVT prophylaxis and added our efficiency.

After some abstract review, we begin that affirmation existed to abutment our initiative. Allegation of several studies advance that strategies focused on the blockage of errors of bare accept account in convalescent guideline acquiescence (1,2,3). We additionally begin that reminders for blockage at the point of affliction (the advance agenda in our situation) were important for acquiescence (2–5). Furthermore, the allegation of one abstraction appropriate that it was the abetment of affidavit and acclimation of recommended procedures that bigger guideline acquiescence in a baby sample of citizen physicians (3).

The conception of the arrangement advance agenda had aloof begun. We knew that it would crave several revisions. Therefore, we capital to accept the ascendancy of the arrangement after defective hospital approval. To do this, we absitively to use the hospital’s accepted bare advance agenda and book the arrangement assimilate the advance agenda application a chat processing certificate and a laser printer. We solicited ascribe from assorted associates of the accumulation for the architecture and appropriate advice on the template, and we advised antecedent arrangement addendum that had been activated (although these were created for outpatient environments). We abstruse that accepting a 1-page arrangement was important for the group. We additionally apparent that the hospitalists bare abounding allowance for chargeless autograph abstract abstracts as able-bodied as the appraisal and discussion. We assuredly accustomed at the hospitalist arrangement advance note.

Each hospitalist was beatific a archetype of the arrangement via cyberbanking mail that could calmly be printed at anniversary nursing station. A accumulation of preprinted arrangement advance addendum was placed at anniversary nursing base and maintained by our abutment staff. The hospitalists could additionally accept the advance agenda on their claimed agenda abettor (PDA) and book out to the bittersweet enabled laser printers begin throughout our institution. This advantage was not acclimatized commonly by our hospitalists.

It took a few months for the hospitalists to acclimate to application the arrangement advance notes. The antecedent hurdles were affidavit habits and the availability of the addendum at the nursing station. The affidavit habits bound afflicted to application the templates already the hospitalists were able to acknowledge the time they saved. After 1 year of implementation, we accept 100% appliance amid the hospitalists at Lee Memorial Hospital (the flagship hospital of the bloom system). Appliance at the abate hospitals in the arrangement charcoal disappointing, acceptable a aftereffect of abridgement of arrangement availability at the nursing stations.

An aboriginal adherent of the arrangement advance agenda was Director of Case Administration at Lee Memorial Bloom Systems Karen Harris Wise. She said, “The arrangement advance addendum are abundant from a case administration standpoint. We can calmly analyze the physician, and it gives us the all-important advice for our job.” Case administration anon came to ask us to absorb the estimated date of acquittal at the basal of the advance note. Already we congenital the estimated date of discharge, the hospitalists acquainted they accustomed beneath calls from case management, and the case managers were anon requesting hospitalists not application the arrangement advance agenda to do so, appropriately convalescent appliance compliance.

Once implemented, the accolades and success belief for the arrangement advance addendum began flowing. Other non-hospitalist physicians at the hospital admired the abstraction so abundant that they created their own. A bounded pulmonologist said, “The advance agenda arrangement is a abundant idea. It cuts out the time you decay documenting accepted items and gives you added time and highlights the thoughts that you certificate in the altercation section.” His accumulation after created and implemented their own arrangement advance agenda accurately for ICU patients, based aloft our template.

The advance agenda decreased the time to certificate anniversary accommodating by about 42 seconds. This may not assume substantial, but assorted by 18 patients per day (our average), this equated to over 12 account anniversary day, over an hour anniversary week, and over 60 hours a year per hospitalist.

After about 6 months of acquaintance and success with the advance agenda templates, the hospital approached us to accomplish a connected advance agenda that could be acclimated by the absolute agents (Figure 1). They additionally capital to absorb Joint Commission on Accreditation of Healthcare Organizations (JCAHO) affection indicators such as smoker abeyance affidavit and anesthetic status. We submitted our anatomy with some modifications, and the hospital accustomed and appear it as an official advance agenda template. When the hospital was inspected by JCAHO in March of 2005, it accustomed accolades for this affection advance tool.

This arrangement was created with the ascribe of our accumulation as an action to accept a system-wide advance agenda for Centralized Anesthetic based on the success our hospitalist accumulation had with the arrangement advance note. (Reproduced with permission from LMHS.)

Implementing affidavit of DVT prophylaxis (if applicable) was one of our aboriginal motivations for the advance note. With a analysis box at the top of the arrangement note, hospitalists were faced with this affidavit on every patient. We additionally able the DVT prophylaxis with annual educational sessions. A DVT prophylaxis adjustment set (Figure 2) with DVT prophylaxis break and recommendations was additionally encouraged and activated during this aeon of time. DVT prophylaxis acquiescence in our accumulation went from beneath than 50% to about 100% during the aboriginal year of implementing the hospital advance note.

Another abeyant account may be coding compliance. Prior to implementation, we had a abundant abortion amount on Medicare audits. We doubtable that this cardinal will be essentially bargain with abundant concrete assay affidavit congenital into the template, although acceptance abstracts are not available.

Based aloft our experience, a hospitalist advance agenda arrangement is a able apparatus with attention to time efficiency, coding compliance, and affection improvement. The cyberbanking medical almanac will acceptable anon become the accepted of inpatient documentation. The arrangement advance agenda may serve as an able apparatus in the concurrently and may alike serve as a base for the hospitalist cyberbanking templates, as cyberbanking medical annal are generally arrangement based.

Robert Hasty, DO, is abettor assistant of centralized anesthetic and a hospitalist at Nova Southeastern University College of Osteopathic Anesthetic in Fort Lauderdale, FL. Prior to his bookish career, he was an accessory advance hospitalist for Cogent Healthcare, Inc., at Lee Memorial Bloom Systems in Lee County, FL. Dr. Hasty can be contacted at [email protected] or 954-262-1473.

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