Admission Orders: Level of care must agree

• The level of care must agree between the Request for Admit (placed by ED) and Admit to Inpatient (placed by admitting team) orders while the patient is boarding in the ED.  If one of these is not correct, re-order it. Don’t cancel the prior order.
• If changing the level of care while still boarding in the ED, place a new Request for Admit and Admit to Inpatient order with the new level of care. Don’t cancel the prior orders. Let the nurse and bed control know.

Inpatient Lab Orders: Time it right

• Routine Lab Collection times: 0000, 0400, 1000, 1300, 1700, 2100
  Labs with an order time set after one of these times will be rolled over to the next collection time.  So if you need “PM Labs”, set a Routine priority at 1700 or 2100.
• Avoid using the Timed Routine lab priority.
• Do not use the Label comment field or Order Comments to communicate to the Lab/Phlebotomy. They cannot see this information when drawing labs.  Instead, call Phlebotomy to let them know if special instructions, e.g. “Please use pediatric tubes”

Remember the Required Provider Note Details

• Remember to fill out the Required Provider Note Information for every patient, every day in the hospital before you write your progress or procedure note

Choose the right Note Type, Correct it before you sign

• Remember to choose the correct Note Type when creating your note.
• If you initially selected the wrong Note Type, you can change it by clicking the blue hyperlink at the bottom of the note before you sign it.

Write the right information on the Discharge Summary

• Discharge Medication List: The auto-populated “Home” Medications should be the same as the Discharge Medications.
  Make sure to do the Med Rec prior to creating the note, or clicking the little refresh button in the Mediation section to update the list.
• Hospital Course: Summarize the hospital course by problem.  A summary is a synthesis of the findings, assessment and course, including rationale to explain events or course of action
• Discharge Plan/Follow-up: Be succinct! This includes the plan for the patient and follow-up.  Deleting the problem list in this section is okay. A bulleted list of plans is okay.