Admission History Changes: Go live November 15th

Why have these changes been made?

  • To standardize and simplify the way we do Admission Histories
  • Changes from a “form for a nurse to complete” to a data base where data collected is shared electronically in various other forms/displays. Also data will be imported – i.e. past medical surgical history imported from provider H&P. Many eyes will see the data.
  • These changes were made by committees made up of staff nurses and were based on their opinions

What are the main changes?

  1. 3 different time phases with 3 different sections of data collection (rather than one nurse having to complete everything in first 8 hours, see details below)
  2. Reminders (Indicators) on whiteboard to show completion status of Admission History form
  3. Orders & consults will be automatically generated when patient has positive ancillary screens (no need to page anyone or make calls, no need to go into HEO/WIZ to order)
  4. Should lead to better vaccination administration compliance (Vaccination schedule protocol triggered by Admission History & Medipac location, Vaccination order automatically generates for 1000 the next day)

Breaking it down…

The new Admission History has three different sections.

  • Section 1: Critical for Safe Care - needs to be completed within 1-2 hours of admission
  • This section includes pt info (height, weight), family names and contact information, allergies, present on admission screen, and alcohol screen
  • Section 2: Plan of Care - needs to be completed within 6-8 hours of admission
  • This section includes tobacco use, immunizations, clergy visit, pain screening, nutrition screen, social work screen, learning readiness
  • Section 3:Discharge Plan and Functional Screen - needs to be completed within 20-24 hours of admission
  • This section includes discharge and functional screens

Also important to note:

  • If you have the appropriate resources available, it may be possible to do all 3 sections in the first couple hours. The new phased section method gives the nurse the option, for delaying pieces of the form.
  • Even if you have passed the 24 hour mark and the data is not complete, continue to collect it. The data is important.
  • When a patient is received from the ICU, be sure to check if the Admission History is completed. In most cases, Immunization Screens would be documented only after the patient is no longer in ICU status. The vaccine indicators (Flu & Pneumovax) will turn yellow when a patient transfers from an ICU and will remain yellow until the patient has been on the non-ICU unit 6 hours before turning red. Once the immunization screen is complete, the indicator turns green. Vaccination orders are auto-generated when the when the Vaccine section in the Admission history is complete.
  • StarPanel tracks each person’s specific data entry. There is no need to start a new Admission History if one has already been initiated. If nurse A completes section 1 and then nurse B fills out section 2, it notes which nurse filled out each individual line. This allows for one document per admission.
  • You should save as “Complete” only after you have documented all data you expect to be able to collect this admission. After the final save, you can still enter information, but any new information or edits will be added as free text amendments instead of altering the original document. Remember: DO NOT SAVE AS COMPLETE UNLESS ALL INFO IS COMPLETED.
  • There will now be a place to note that the patient has brought CPAP, medication pump, or another medical device from home (including home vents and other respiratory equipment).

Take a look at the changes:

Go to StarPanel and type in one of the following MRNs listed in the handout.

Click on actions (in blue next to the patient’s name) and then click on Admiss.Hx Form (TRAIN)

While looking at form: note major changes, point out 3 sections, explain vaccination section and how the orders are auto generated for the next day