Apply Label. Page 1 of 7 VALLEY REGIONAL HOSPITAL - KARDEX. Patient Profile: Pt Name: Date Adm to Med/Surg Unit: Physician: Covering/alternate:

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1 VALLEY REGIONAL HOSPITAL - KARDEX Patient Profile: Pt Name: Date Adm to Med/Surg Unit: Physician: Covering/alternate: Diagnosis Apply Label ALLERGIES: Order entry Y N Admission Ht: Wt: Order entry Y N Surgical Procedures date): NOK/relationship: Contact # s / Presentation to Hospital: Relevant medical and/or surgical history: Date Data Base Completed: No Code (date) Expected Death (date) Anticipated Date of Discharge: Patient and Family Goals as per Database Admission MRSA swabs Repeat MRSA swabs due Isolation precautions Braden Scale due Pertinent Ongoing events/communication Page 1 of 7

2 Interprofessional Goal: Interprofessional Goal: Interprofessional Focus Sheet Profession Date Focus Goals Interprofessional Team Conference(s) Meeting dates: Discipline(s) present (assign number as corresponds with meeting date) Chaplain Family Palliative SLP Clinical Support Health Psychology Pharmacy Other: Dietician OT Respiratory Discharge Planner PT RN/LPN Page 2 of 7

3 Achieved (date) Modified (date) Not Achieved (date) Review date and comments Review date and comments Significant Events Apply Label Page 3 of 7

4 Interprofessional Consults Order Date Date Entry Not d Visited Patient Navigator (Cancer) New diagnosis of cancer or recurrence who appears overwhelmed with current circumstances, client of CC Navigator, barriers to cancer care, financial issues related to cancer diagnosis Chaplain would like a visit, new diagnosis; terminal diagnosis; few social contacts; family issues; spiritual/emotional distress Dietician Difficulty swallowing, Aspiration pneumonia, severe reflux, pancreatitis, recent wt loss/gain, poor appetite/intake, poor dentition, Crohn s/colitis, vomiting/nausea, enteral nutrition, TPN, new diabetes, constipation, multiple food allergies/intolerances, new cardiac/chf, new celiac diagnosis. X Discharge Planner complex discharge identified, Financial needs identified N/A X Enterstomal Therapy/Wound Care any patient with ostomy, pressure ulcers, wounds, incontinence, Braden Scale < 12 X Health Psychology - (1) lifestyle changes/stress management with dx cardiac, diabetes, IBD, COPD, hypertension (2) Physician request for difficulty N/A coping (anxiety, depression) with issues related to physical illness (e.g. dx, tx, changes in functioning X Heart Function Clinic Nurse client of Heart Function Clinic, client of cardiac N/A rehab program Occupational Therapy Stroke, pressure ulcers, Braden scale < 12, end stage COPD, CHF, palliative going home, recent amp, arm nerve pain, or edema, hx falls, lives alone with difficulty, needs w/c, cannot use call bell, X Palliative Care client of palliative care - FAX referral form X Pharmacy enteral feeding, all new ACS/MI/Stroke patients, noncompliance special medication needs (literacy challenges, vision, etc) are identified, MSI N/A (special exception medications), SAP and non-formulary meds, Medication counseling Physiotherapy acute stroke, acute neuromuscular disease (MS exacerbation, guillian Barre, Parkinson s, ALS etc), chest complications (COPD, pneumonia, atelectasis), prolonged immobilization/weakness, post-surgical with surgeons referral (amputation, joint replacements, general, vascular, cardiac etc), postfacture not requiring surgery, moderate to high risk for falls, assessment for gait aides, transfer training. Respiratory Therapy admitted with respiratory dx, tx O 2, tx inhaled med, home O 2 user, trach, OSA Speech Language Pathologist referral is appropriate for anyone who is experiencing difficulty communicating including: difficulty expressing/ understanding language, unclear speech, laryngectomy, voice problems, or non-verbal status (e.g. may require communication supports/aids while trached). a Physician s referral is required. Referrals for swallowing difficulties are to be made via the Dysphagia Team and also require a Physicians referral. X Needs phone call to confirm referral ASSESSMENT Page 4 of 7

5 Kardex updated Mental Status: D/N Patient Name: V/S: T P R BP O2 Weigh I/O Accucheks Close observation Safety measures Nutrition: Diet Dr. order Present level Complete Assist Self Other: dysphasia, tube feeds Respiratory: Chest auscultation O 2 supplement Other: (ex. trach, sats, physio) Cardio/Vascular: Monitor Telemetry Pulses Other CSM Eliminations: Last BM Incontinent care Perineal cream Ostomy care Foley cath Date inserted: Size Interim cath CBI Hygiene: Self Assist Complete Tub/Shower Skin Integrity: Intact Abnormal Braden Score Airbed Heelboots Turn q 2 h Other: Catheter irrigation Abdominal: Assessment Abdominal girth NG Feed tube (type) Flushes placement BS check Pain: Assessment PCA dose limit lockout CADD pump Dose Epidural SCBF Other Bolus Dressings/Treatments: (date, site, type, etc.) cm Mobility: Activity ordered Self Assist Aids Lift Drains: Chest Tube Surgical Drain Hemovac IV Therapy: Date Solution & Rate Change Line Due Site Change Page 5 of 7

6 Date Due Diagnostic Test Order entered Done Apply Label Date Due Diagnostic Test Order Entered Done Physician Consultations Date Entered/ notified Date visited Page 6 of 7

7 Kathie Swindell is that right Jen? Page 7 of 7