PsychNursing Admission Process: ED Admit

Version 2 6/25/2013

ED Nurse

  • Enters Home Medications, Allergies and Height and Weight
  • Before patient is Admitted, ED RN edits ED Assessment statuses to Complete
  • ED RN Calls Inpatient RN for verbal hand off
  • Both Inpatient and ED RN to use EMR to Review Patient Information (Orders, Meds; etc)

Inpatient Nurse

(Upon patient’s arrival to the inpatient unit)

Process Transfer Orders via PCS Status Board:

  • Click [Lists]
  • Find by either [Find Account] or [Find Patient by Inpatient Location]
  • Click the [Add to My List] footer button
  • Click the [Transfer] flag within the PCS Status Board under the Orders Column
  • Click the [Manage Transfer] footer button
  • Click the [Process Transfer] footer button
  • Click [Yes] to process the transfer orders
  • Documents Arrival to Unit – Admit/Transfer Assessment (Worklist)

Document Arrival to Unit:

  • Click [Worklist]
  • Document the Arrival to Unit – Admit or Transfer assessment

Review Home Meds, Allergies, Height/Weight:

  • Click [Clinical Data]
  • Click on the [Home Meds] tab
  • Confirm Prior Entries (Last adm)
  • Enter New Meds
  • Edit/Delete Inaccurate home meds
  • Click on the [Allergies] tab
  • Review or add any additional allergies
  • Click on the [Main] tab
  • Review Height and Weight
  • Click [Save]

Add Psych Adult Plan of Care:

  • Click [Plan of Care]
  • Click the [Add] footer button
  • Select [Psych Adult Plan]
  • Save

Admission Documentation (Worklist):

  • Admission Assessment
  • Past Medical History
  • Arrival to Unit – Admit or Transfer
  • Age 18+ Opt Out Vaccine Assessment
  • Fall/Risk/Safety Assessment
  • Braden/Skin Risk Assessment
  • Vital Signs
  • Psych Physical Assessments (ADM)
  • Cardiovascular
  • Respiratory
  • GI
  • GU
  • Skin
  • Neuromuscular
  • Psych Legal Status

Individualize the Plan of Care:

  • Document: Psych Individualized Focus of Care Intervention
  • Select One Primary Problems to add to the patient’s plan of care
  • This will add the Shift Assessment
  • Select Additional Problems that Apply

Further Customize:

  • Edit the Frequencies based on the protocol per unit and patient status
  • Edit the Frequency on the worklist by clicking directly on the current Frequency and editing the text
  • Indicate the Disease Process that each Problem relates to and the specific Goals which will be set to achieve the Outcome
  • Click [Plan of Care]
  • Click within the [Item Detail] column for the problem or outcome
  • Click [Edit] within the text box
  • Click [Save]
  • Edit the Target Dates by clicking in the Target Date column and adding the date

Order Management - Nursing Process

  • Acknowledge orders (Status Board)
  • Discrepancies should be called to Pharmacy
  • Administer Medications (MAR)
  • Scan Patient’s Wristband
  • Scan Medications

Version 2 6/25/2013