Section

Subsection

Row Name (20 Char)

Row (f, a, n)  f=Fixed     a=Automatic n=Normal

Lists: short name (7 char)

Lists: Long name (16 char)

Checked

Events

Communication

MD Notified, Name

A

String 7

Safety

MD Notified

A

MD Present

A

String 7[1]

MD Notified For

A

Referrals

A

Rounds

A

POC Testing

Glucose, Fingerstick

N

Glu Finger,Critical*

N

I Na+

N

I K+

N

I Chloride

N

I BUN

N

I Ca++

N

I Glucose

N

I Hemoglobin

N

I Hematocrit

N

I pH

N

I pH Venous

N

I pH Corrected

N

I PaCO2

N

I PaCO2 Corrected

N

I CO2 Venous

N

I PaO2

N

I PaO2 Corrected

N

I HCO3

N

I Base Excess

N

I SaO2

N

I TCO2

N

ACT VAD, sec

N

Guaiac Stool

N

Guaiac NG Drnge

N

Cultures

Lab Specimen Sent

N

Test/Procedure

Non-Invasive Procedr

N

CXR Confirmation

N

CXR Confirmed by MD

N

Invasive Procedure

N

Off Unit Procedure

N

Cardioversion Mono

N

Cardioversion BiPhas

N

These rows and lists are preliminary, I have various questions about the lists I've been given and will need to clarify them.

Events

Code Blue

N

Readmit: < 24 Hours

N

Return To CVOR[2]

N

Intubate/Reintubate

N

same row as in Resp

Return To OR

N

Discharge AMA

N

Adverse Reaction

N

Fall

N

Security Needed

N

Donor Network Called

N

Death

N

Seizures

Seizure History

N

Seizure Precautions

N

Seizure Outcome

N

Suicide

Suicide History

N

Suicide Precautions

N

Suicide Outcome

N

Fall Risk Hx

N

Fall Risk, Current[3]

N

Fall Risk, Teaching

N

Fall Risk Intervention

N

Fall Risk Outcome

N

Falls Risk

3 scales presented

Morse Fall Risk

History of Falls

N

Secondary Dx

N

Ambulatory Aid

N

IV/ Saline Lock

N

Gait/ Transfers

N

Mental Status

N

Morse Fall Total*

Kaiser Fall Risk

Previous Fall

N

(Walnut Creek)

< Gait; < Strength

N

Confusion/< Judge

N

Meds / Dizzy

N

Nocturia/ Urgency

N

Arrythmia/Hypoten

N

<Vision / Hearing

N

Fall Scale Total*

N

Schmid Fall Risk

Mobility

N

Mentation

N

Elimination

N

Prior Fall History

N

Current Medictions

N

Schmid Fall Total*

N

Teaching

Teaching,FallPrevent

N

Taught to Whom,Fall

N

Response,FallPrevent

N

AdditionalNeeds,Fall

N

Restraints

Restraint Teach To

N

Restraint Rational

N

Restraint Alternatives[4]

N

Restraint Orders

N

Restraint Type

N

Restraint, Applied to

N

Restraint, Pt Checked

N

Restraint Off q2h

N

Restraint Site Conditin

N

Side Rails

N

Restraint Evaluation

N

MD Order Written qD

N

Restraints On/Off/DC

N

Clinical Rationale

N

Behavioral Rationale

N

AlternativesAttemp 1

N

AlternativesAttemp 2

N

AlternativesAttemp 3

N

Restraint Type/s

N

Limb Restraint Loc

N

Frequent Observation

N

Restraint Site Cond

N

Restrnt Release q2H

N

Intervention 1

N

Intervention 2

N

Intervention 3

N

Pt Response Restrnt

N

Teaching

Teaching, Restraints

N

Taught to Whom, Rst

N

Response, Restraints

N

Additional Needs,Rst

N

Problems

Safety Risk to Self

N

Safety Rsk to Others

N

Interventions

Basic Unit SOC

N

Restraint P&P

N

Falls Prevention P&P

N

Falls Prevent Progrm

N

Outcomes

<Patient Safety Risk

N

<Risk to Others

N

note: referrals for this section:  CNS? Any other referrals?

Notes:  Falls Preventions Interventions are in the P&P; Protocol, SOC, etc.

Examples of interventions:

Fall History

Utilize Protective measures to prevent injury

Bed/Chair exit alarms

Non skid Slippers

Visible Room

Elimination

Commode at Bedside

Scheduled Toileting q 2 hours

Do not leave patient alone on commode or in Bathroom

Confusion

Visible room

Close Supervision

Family companion

bed alarms

Geriatric and or Psychiatry consult

Dizziness

Orthostatic VS q    Hours

Vertigo

Patient Instruction regarding slow, progression to upright position

Syncope

Exercises

safety:  sit down if feeling dizzy

Behavior

Pt Consult

Gen Weakness.

Exercises to promote strength

Assist Patient with ambulation