Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Sign outs Good communication is essential and critical for appropriate patient care Difficult to master the technique to include all pertinent information in a concise manner Process not uniform More “handoff’s” due to duty hour restrictions Patient Hand Off Tool (HOT) Used by most services in the hospital for communication and sign out Prepared by the primary team but can be edited by any service/consultant Intern nightfloat will have a copy of the HOT on each patient Sign out Process Should be done in a quiet place with the least number of distractions possible Start with your sickest patient Make sure ALL your patients are included! Sign Out Process S- sick and code status I- ID statement G- General hospital course N- new events O- overall health status U- upcoming events/possibilities T- “to do” overnight Discharge Summaries Are dictated at UH; typed at VA Must be done DAY OF DISCHARGE Tag a day of discharge progress note at end to save you time Thorough yet not too lengthy! How To Dictate Dial 66000 in house Dial (216) 286-6000 from outside Physician ID # 1# 7# Medical Record Number # “begin dictation”…. How To Dictate “This is Dr. x dictating discharge summary for patient x MR number xxx” Date of Admission; Date of Discharge Attending on service Discharge Diagnosis Procedures performed HPI/Hospital Course Discharge medications* Follow up appointments follow up items Condition and disposition at discharge Day of discharge progress note copies of dictation you want sent PCP, Consultants How To Dictate Important Keypad numbers 5 is pause 2 is to resume 9 for confirmation number Remember to divide paragraphs Can be amended Can be done from home Questions