What should be included in assessment and plan?

What should be included in assessment and plan?

What should be included in assessment and plan?

Assessment & Plan

  1. Write an effective problem statement.
  2. Write out a detailed list of problems. From history, physical exam, vitals, labs, radiology, any studies or procedures done, microbiology write out a list of problems or impressions.
  3. Combine problems.

What is system based approach?

A systems-based approach uses a standardized set of management steps that are sequential and may be applied to any major undertaking. This dictates that overarching objectives, strategies, and tactics are established to promote effective response management and consistency.

How do you work with ICU patients?

My 5 step pre-rounding process:

  1. Read the history & physical, consult and progress notes to determine who is the patient and why are they here.
  2. Review home medications.
  3. Review labs, cultures and imaging reports.
  4. Review the bedside flow sheet.
  5. Review current medications.

What is fast hug bid?

To introduce the Fast Hug mnemonic (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, stress Ulcer prevention, and Glucose control) as a means of identifying and checking some of the key aspects in the general care of all critically ill patients.

What is an assessment and plan?

The assessment and plan (abbreviated A/P” or A&P) is a component of an admission note. Assessment includes a discussion of the differential diagnosis and supporting history and exam findings. The plan is typically broken out by problem or system.

What is an example of system based practice?

Some examples of systems-based practice in healthcare are approaching identified problems with the goal of fixing them rather than just relying on a workaround, working in interprofessional teams to enhance patient outcomes, and understanding how all the different care settings work together for patients.

What are the principles of systems-based practice?

Systems-Based Practice requires residents/fellows to demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

What is the Abcdef bundle?

The ABCDEF bundle includes: Assess, Prevent, and Manage Pain (A), Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT) (B), Choice of analgesia and sedation (C), Delirium: Assess, Prevent, and Manage (D), Early mobility and Exercise (E), and Family engagement and empowerment (F).