Connect Care StreetSmarts - Admission Workflows
This section summarizes recommendations about how to use Connect Care to support admissions to inpatient facilities. The focus is on prescriber accountabilities when tasks may be shared by more than one individual. Prescribers can hand off to one another while an admission workflow is in play. Prescribers may also work in teams, including trainees, where tasks are assigned to different individuals.
Workflow Sequencing
Completing a full patient admission can take time, especially for clinicians new to Connect Care workflows. In addition, front-line pressures may present multiple simultaneous admissions. It can help to break the workflows into discrete steps so that work can be initiated, interrupted, then resumed. The following steps and sequencing can be adapted to different work contexts.
Bedside Introduction
Without looking to the patient's health record (avoiding expectation bias), go to the bedside to quickly gauge the patient's acuity, stability, cognitive state and social supports.
Introduce oneself and one's role, indicating that there will be a pause for chart review before returning to complete a history and physical examination.
Clarify what the reason for and manner of presentation is, noting the pre-emergency context (e.g., home, home care, other facility, etc.).
Determine whether alternate informants will be important to completing the admission and arrange for their presence at or just before the full bedside assessment.
Initial Chart Review - Use the Admission Navigator
Open the patient's chart, ensuring that the Sidebar is also opened.
Use interactive charting to complete the "Patient Presentation" appearing at the top of the "Transition Planning" sidebar section.
Open the Admission Navigator within the patient's chart, noting the instructions at the top.
Use the Sidebar Index "Notes" link to open listings of prior summative documents (e.g., discharge summaries) in the sidebar. Items can be selected to review prior documentation in the Sidebar while working on Admission Navigator sections.
Update the Problem List and Medical History (moving items between these lists as needed).
Take note of pertinent surgical, family, substance use or social history entries that may need validation.
Note whether home medications have been entered (by other staff).
Hypothesis Generation and Pre-admission Orders
By this point, an impression of the reason for presentation will form together with a sense of that the principal hospital problem will be and awareness of co-morbidities that could affect or be affected by the principal problem.
Take mental note of clinical hypotheses that will be tested during subsequent bedside interactions.
There may be important orders to enter (beyond those already placed by emergency clinicians) to support admission decision-making.
Bedside Assessment
Further characterize the patient's presenting (principal) problem, clarifying its onset and subsequent evolution.
Complete a review of systems, including positive and negative symptoms pertinent to the working hypotheses.
Verify a best possible medication history while also noting significant adverse reactions to medications.
Complete a physical examination, again focusing on positive and negative signs pertinent to working hypotheses.
Secondary Chart Review and Admission Orders
Refine the problem list, history, substance use, or social history sections as needed.
Validate the best possible medication history and adverse reactions record.
Complete the "Transition Planning at Admission" section of the Admission Navigator, using interactive charting.
Open the "H & P Note" section of the Admission Navigator and initiate a "Basic" or "Advanced" (problem oriented charting) templated History & Physical note. This can be left open, using interactive charting while completing the history of present illness, review of systems, physical examination and social documentation.
Review the emergency room laboratory and imaging findings and use the SmartLists provided to selectively add pertinent findings to the admission History & Physical Note.
By this point, enough will be known to choose an appropriate admission order set, taking care to avoid repeat of investigations already performed in the emergency department. The expected discharge date and patient's primary provider team should be entered with the admission order.
Final Assessment and Plan
Fine tune the active problem list and generate an assessment and plan for each problem, keying overall hospital operational needs (e.g., thromboprophylaxis) to the principal problem, then share the admitting History & Physical note. Leave signing to the most responsible provider.
Consider any additional orders needing attention in the emergency department (many clinically appropriate orders are best deferred until later in the admission when the patient is no longer acutely unwell).
A final bedside visit can help the patient and their supports understand and consent to the plan; giving additional opportunity to confirm goals of care.