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Initial admission

hi my name is Andrew and I'm going to be going over the interdisciplinary initial assessment this is a tool that we will used when a patient is admitted to the hospital for the first time during their admission state the initial assessment will be located on your work list when the patient is admitted and entered into our computer system it is an automatically generated or populated field that you will find in the work list to document usually it's going to be found at the top of your screen as one of the newest items on your work list in this situation the initial assessment is here up top so I'm going to go ahead and click on that once or press ok or can also double-click on that item to open that field when you read the transaction line down below it's going to ask them to choose an option of what I want to do I want to document on the initial assessment so I'm going to click document and it's going to ask me enter the date and time now usually one of the patient comes to the hospital and is admitted in the in their room we will duel our assessment and then go back and chart in the computer system it's asking me if I did this assessment now what we're going to decide say today is the patient came in at ten it's now ten forty and we're going to see the patient came at ten 10 and the initial assessment was done at 1010 so I'm going to change his time to 1010 and I'm going to select ok now we're going to go ahead and get started with the documentation portion the first question it asks us is chief complaint and we're going to see the patient came in with abdominal pain you'll notice that in this first section is bolded anything that is bolded which are numbers 1 2 3 4 & 6 must be document to the computer system anything is not bolded we recommend that you document those items but are not mandated we're going to go ahead and press ok that we did the chief complaint the next one is going to ask as the present history illness history we're going to go ahead and document that by pressing d and we're going to say that on set was three days ago and press enter the description we're going to say aching pain and this is all what the patient has told us during our admission press ok ok one more time T it's the next cream the next screen is asking us what is the illness disease history if there was a history of the patient of the past of the disease or a past medical history we will click on d4 document or we can bypass that if they didn't have any history and click on no past illness disease history which I'll do now the next question is asking us about the surgical history if the patient did have surgical history you would click on the d4 document or N or click here no past surgical history which is what we're going to do and same for the next question any injury history we're going to see that there was none so we're going to document no prior injury history the next question is asking if there are core measures for this patient the patient came with abdominal pain it does not meet any criteria for these core measures so we're going to go ahead and select none if the patient did come in with the core measure such as pneumonia we would select in the moment category when you are documenting we are recommending that you fill out these next few lines here that are non bolded to obtain better history of the patient however for training purposes we're going to go ahead and bypass this and you'll notice that our assessment screen options number one the past medical history there is nothing here that is doc it is blank it does not say no data or incomplete as we complete each of these sections this no data incomplete section will disappear I'm going to go ahead and document the rest of the assessments and show you how easy it is to document the next section is the health history we're going to click on there we're going to assume that the patient has no health history and the only thing that patient takes at home is aspirin the first section that says home medication so we're going to go ahead and click on there and the next section says select medications to edit or choose an option and we're going to click on the add because we want to add that ass when the patient takes to medicate it says at the bottom enter partial medication name so I'm going to put aspirin now I'm only going to spill on halfway i'm going to put the dash which is also known as that wild card and press ok and it's going to find everything associated with the word a spi which is what i typed i'm going to click on that aspirin number one press ok and we're going to say that the patient takes that chewable tablet 81 milligrams daily so we're going to go ahead and click on that number one press ok and the daily is number seven every day and it is formulated as aspirin oral tablet 81 milligram or dispensed that way so we're going to choose that one if there's any other documentation you need to fill out here the patient instructions reason ordered by last date taken you can fill out I'm going to bypass this just for the training purposes so we can move forward and you'll notice that my aspirin pulled up here on the health history portion of my home medications if the patient did have more home medications this is the time where you would click the add category in the bottom of the screen and add the other medications here we're going to assume the patient is only taking the aspirin and that's all we're going to document for that the next is the latex precautions we're going to click on that field and the assets of the patient has latex precautions we're going to say no advanced directives we're going to say unable to determine substance abuse we're going to say the patient is not does not abuse any substances will say no none same thing with tobacco we're going to say that he'd never smoked which will be numbers for any drugs we're going to say never used select ok influenza season if it is influenza season we are required to document if the patient was immunized or not however it is not influenza season so work in the same no pneumococcal screening and we'll go ahead and click on that and we're going to say that the patient was immunized at the age less than we're going to say age is 65 and above immunized prior to admission because the patient is 92 years old and we are assuming that he was immunized based on his assessment or asking him the date we can say the patient was immunized last year which would make it 2013 and press ok and our health history portion is completed we'll press ok again and you notice that fell off the screen too so the patient came in with abdominal pain everything else is okay on the patient according to my assessment so I'm going to show you how fast and easy we can document that so we're going to go to the neuro assessment and it says number one in bolted within normal limits and the patient is within normal limits so I'm going to press no exceptions if I press ok it goes down through the whole thing and it's filling out that everything is ok for me i'll press ok and that fell off on my list ENT assessment based on my assessment he was perfectly fine i'm going to click on number one with no exceptions everything is automatically populated there's no problem with a patient with the ENT i'll press ok we'll go to cardiovascular and do the same thing it's asking me if the patient has a pacemaker we're going to say no respiratory assessment we're going to say that he's perfectly fine there no exceptions oxygen therapy that he's on room air get down to the GI GU assessment ok we're going to say that he's complaining about that abdominal pain so we're going to say abdominal characteristics abdominal character we're going to click on that you'll notice that because I selected a problem with that abdominal characteristic it left the abdominal character open so I need to document their we're going to say that his abdomen is firm distended ok and his bowel sounds our absent to all quadrants last bowel movement this is when what we would ask the patient and we can click on number one as the date and specifically we're hypothetically going to say that the patient told me that his about last bowel movement was four days ago so i want to put 0 3 4 days ago from the 29th which is today's current date down here in the bottom right of the screen is the 25th so I'm just typing 25 and we are in according to the bottom of the screen 2013 7 foot 15 i'll press ok and the date automatically populates first ok now to go to the next supreme the notice that turned a bold color that means that there was a problem associated with that and everything that i documented in the respiratory cardiovascular ENT neuro assessment is not bolded hence because there was no problem associated with that i did say that there was something wrong with that abdominal characteristic that's why it is bolded so we're going to go ahead and document through the rest of this portion of the admission and i'll show you that since there's nothing wrong with the musculoskeletal nutrition function fall pain and so forth excuse me pain is the google document that there's something wrong and everything else will be ok so i'll show you how that goes click on musculoskeletal assessment we're going to say there's nothing wrong so we select no exceptions if there was something wrong this is the category where you would select something same thing with the nurse the nutritional screening home diet we're going to say eats regular food newly diagnosed diabetes we're going to say no renal failure no weight loss no reduced intake no chewing difficulty no diarrhea no nausea vomiting no tube feeding though is the patient on tpn we're going to say no are there any rooms no we're going to click on functional assessment now is there any acute changes we're going to say no acute it's all populated for me I scroll down any problems with swallowing we're going to say no speech no and we're at fall risk so we're going to click on the bold part number two we're going to say if there's notes exclusions and you fall history we're going to say no does he have any problems to elimination pick the correct category we're going to say no problems medications we're going to say he does take he is on one medication which is that aspirin if that is labeled as a fall risk drug you can select that it is a blood thinner so we're going to label it as a high followers drug usually high father's drugs would be like blood pressure medications narcotics and so forth the equipment we're going to say he doesn't use any equipment mobility we're going to say he does not have any risk factors and the cognition were going to say that he's perfectly fine so what we're doing here the whole goal here is we're giving him the our patient points in relation to assessing him for his fall risk the more problems that the patient has the higher points the patient will obtain the higher points the patient has the more chance they are or at risk the r4 falls into the pain assessment we're going to say that the patient is complaining of is having pain and it's complaining of that abdominal pain hence his admission say the towel roll pain level is a to his paint on the pain scale Merc we're going to say that his pain level right now is a five in his abdomen it's acute and is the pain level acceptable to the patient we're going to say no I'm going to say that we provide education and make sure that education is provided even verbally approach it handout from an appropriate website like cranes or more are Mo's B's person okay and we're almost done with our admission assessment we're going to go down to the psychosocial section we're going to state their beliefs for their cultural and spiritual beliefs will say none cultural beliefs none and so forth their mood attitude appropriate risk for suicide we're going to say no do they have a plan no Lisa name no previous attempt no chronic illness no life-changing event no depression no violence or abuse the patient feels safe yes do they feel threatened know and so forth throughout this admission process you will document the whole entire admission be sure that the end you do except when you accept it is saved in the system thank you