1. Past Medical & Surgical History
Admission History Data Base Changes
Issues with current
Admission History process
Changes were made!
Section I
Section II
Section III
97% of admission hx started- only 10 % completed
No reminders if not finished
8 hours is not long enough time to get it done.
It doesn’t track who entered each piece of data so I start a new one even if there is a draft.
Redundant information collection- Patients complained they have already answered Qs.
No one looks at it! This is just a waste of time!
When I am worried about keeping patient alive upon admission, I shouldn’t have to document discharge plans.
Must leave Admit History form and go to HEO to enter orders.
Nurses “live” in HED – can’t we put this in HED???
TOO LONG!
Admission History data is collected within 24 hours of admission, or in a shorter timeframe appropriate to the patient population, based on anticipated length of stay. The Admission History data set is divided into three sections.
Required in order to initiate safe patient care.
Complete section 1 to the extent possible during the initial admission period. (generally first 1 to 2 hours following admission).
Some data will populate from other VUMC clinical information systems or from pervious admission histories
Populated data is carefully reviewed and revised as needed to ensure complete accuracy.
Required for initiation of individualized Plan of Care.
Collect and document data within the first six hours of admission.
Note: Plan of Care must be started within eight hours of admission.
Required for initiation of individualized discharge plan.
Collect and document data within the first 22 hours of admission.
Note: Discharge Plan must be started within 24 hours of admission.
Past Medical & Surgical History
Physician responsibility to enter and link displays in Admission History
Physician will be notified of positive Functional screens as only providers may order Rehab evaluations in Tennessee
New visitor policy: patient is allowed to have support person stay with them 24/7
Data will be shown on OPC initially and then other electronic documents later
Can I do all sections at once?
YES!
The admit history may be completed at one time if that is practical.
Important thing is to get the data collected.
Previously all data had to be collected within 8 hours.
Now have up to 24hrs to collect.