Shift routine: (this may differ slightly between nurses and shifts)
Report (via Care compass)
SBAR section (In patient section/Summary)
Results Review for Labs
Vitals Validate (Enter Vitals Manually TELE) - PAIN
Q2 PCU/ Q4 TELE
Head to Toe (Q-shift)
Update PRN during shift q2-4 if ordered (ex. Neuro)
ADLs (qshift minimum)
SCDs (qshift minimum)
TURNING q2hrs bedrest patients/High Risk for Impaired skin
Meals TID and needed
Blood Glucose
Sliding Scale
MAR
Scheduled
IV
PRN and PRN recheck
MORSE – NIGHT SHIFT (q24hrs)
BRADEN SCALE – DAY SHIFT (Q24hrs)
Orders – click “orders for nurse review”
Evalysis – enter @ 0500/1300/2100
ORDER ENTRY DETAILS (QSHIFT)
Intake and output
Adult Lines (q 2 hrs)
Careplan plus End of shift evaluations
Braden/Morse (QShift)
RESTRAINTS
NON behavioral – q2hrs
BEHAVIORAL q15min
As Needed Charting
Nurse Progress Notes (For other charting needs, ex. Incidentals, other situations)
PRN others (iView I&Os)
Adult Education
Pre Op – remember to add navi band in iView
Bedside sedation
Other special procedures…
Admission:
Basic Admission Information Adult (LVN ok)
V/S, Height&Weight, Safety, Belongings
Admission History Adult
General Info, Pain, Allergies, Etc.
Braden Scale
Morse Fall Scale
Immunization Screen
MEDICATION RECONCILIATION
Order Entry Details
Associate Monitor (PCU only)
Orders
Assessment
Order/Customize Suggested Care plans
EDUCATION
Transfers:
Transfer IN 4w
PM conversation – pick pt location when pt arrives in bed
Transfer OUT of 4w
PM conversation – pending transfer
Call pt flow for transfers to PCU/TELE/ICU
Discharge:
Discharge Readiness (Can be updated q day till discharge)
See discharge section
Med recon (Prescription)
Documentation
Patient family education (Krames)
Follow up (Appointments)
Results
Nursing documentation
DC order
Care management
Vaccine – look back at vaccine screen form
Pneumococcal and Flu
DC Lines and document in iView
PCU - Disassociate cardiac monitor in iView
SIGN
If pt discharged to psych (8w/1south) pt needs to be completely discharged to psych, not transfer
Discharge to SNF or other Facility
If patient still has a hard chart
