Download 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
Red Flag issues or
concerns:
Follow-up Plan and
Responsible Person
Draft 9/2010
Other information: (PMH/ PSH)
Evidence-based
practice
Infection prevention and Hosp
acquired conditions
Medication Safety
Patient/Family/Caregiver
Engagement
Care Transitions and
Handoffs
Heart failure,
pneumonia, AMI,
stroke core measures
DKA mgmt
Intravenous access
Foley catheter
Self-management education
-medical condition
-medication
-follow-up plan
-hospital-acquired condition
prevention
Primary caregiver updated
Discharge date, location
Sepsis screen
On any high risk medications?
-anticoagulation
-pain medications
-insulin
-intravenous drips
-chemotherapy
Medication reconciliation
Restraints
Pain management
Mobility/functional status/ fall risk
Skin status/pressure ulcer risk and
prevention
Other:
Other:
Discharge by 11 am?
Readmission risk factors
Other:
Mental status/Delirium
VTE/DVT prophylaxis
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 physician
Prescriptions to be filled
by SJMH?
Polypharmacy – on more than
(threshold could be higher—i.e. 10
regularly scheduled meds in hospital)
Follow-up Plan and Responsible
Person
Projected LOS
Follow-up Plan and Responsible
Person
Follow-up Plan and
Responsible Person