Interdisciplinary Rounds Checklist

Document 7, Coaching Call 1, 06/21/2011

Interdisciplinary Rounds Checklist

Date:

Patient Name:______

Attending Physician:______

Primary diagnosis and active issues:

______

______

______

______

Culture of Safety/
Living Situation & Barriers / Evidence-based practice / Infection prevention and Hosp acquired conditions / Medication Safety / Patient/Family/Caregiver Engagement / Care Transitions and Handoffs
Red Flag issues or concerns: / Heart failure, pneumonia, AMI, stroke core measures
DKA mgmt / Intravenous access / On any high risk medications?
-anticoagulation
-pain medications
-insulin
-intravenous drips
-chemotherapy / Self-management education
-medical condition
-medication
-follow-up plan
-hospital-acquired condition prevention / Discharge date, location
Sepsis screen / Foley catheter / Medication reconciliation / Primary caregiver updated / Projected LOS
Restraints / Mobility/functional status/ fall risk / Other:
Polypharmacy – on more than (threshold could be higher—i.e. 10 regularly scheduled meds in hospital) / Other: / Discharge by 11 am?
Pain management / Skin status/pressure ulcer risk and prevention / Readmission risk factors
Other: / Mental status/Delirium / Follow-up physician
VTE/DVT prophylaxis / Prescriptions to be filled by SJMH?
Nutrition/weight
Glycemic control
Bowel issues
Documentation of POA conditions
Renal function/electrolytes
Polypharmacy – on more than 6 regularly scheduled meds in hospital
Follow-up Plan and Responsible Person / Follow-up Plan and Responsible Person / Follow-up Plan and Responsible Person / Follow-up Plan and Responsible Person / Follow-up Plan and Responsible Person / Follow-up Plan and Responsible Person

Draft 9/2010