TeleTracking
I recommend when you are both AM and PM rounding that you take 30 seconds to launch a list of nursing phone numbers as detailed below. This will allow you to call nurses to get the complete information you need much more efficiently.
AM chart rounding
Same way every time, you check the following tabs on Powerchart, recommended in the following order but do whatever pleases your workflow.
- 36 hour view and free text documentation – recommend start with these, you’ll see random orders and notes from nurses that you can then investigate in the notes (faster than going back to notes)
- On 36 hour view: Look at meds, both current and future
- On 36 hour view: Look at all orders since you last rounded
- On Free Text – you'll see PT/OT/SLP notes with recommendations (faster than opening forms)
- Orders
- Check diet
- Check if labs are ordered
- Labs
- Scroll to the bottom and look at every single lab.
- If they have not resulted, check that they are ordered, call nurse to see if they are a difficult stick etc.
- Micro +/- Microviewer
- Microviewer will have cultures that are in lab but not resulted yet, this is useful to know.
- IView/I&O
- check lines
- check drains and the time they were last charted
- for every patient with a drain, I have had 100% success in never having to call a nurse to update drain outputs by simply putting in a continuous nursing communication note stating “please kindly chart all drain outputs by 4am and 4pm prior to NSGY rounding”
- for patients with I/O needs (DI on the floor, spasm patients in ICU, etc.), I have also had nearly 100% success with a continuous nursing communication note stating “please kindly chart all I/O prior to NSGY rounding by 4am and 4pm every day”
TIP:
- PowerChart Notes - scroll down to plans right away, you need to read every single note
- Check VueMotion, you need to know about every overnight scan whether we ordered it or not.
- For ICU patients, call the overnight APP and fly through updates after you have chart rounded and ask them questions about why they did things.
PM chart rounding
- Check all labs
- Check all final reads on scans (this is also how we get fucked)
- Check all notes – scroll down to plans right away
- Check 36 hour view since the morning.
- TIP: an easy way to find out if your boxes are done is to kindly call the nurse and run through their patient. Gomey things like is the foley out, did they get a unit of blood etc. can be discovered before they are even charted.
- For ICU patients, must call and run the list with them.
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