Connect Care Training and Admission Orders

Connect Care Training

All sites use Connect Care for inpatients.  Please review the CC training so that you are familiar with how to find information, do admissions, do progress notes, pend orders and pend discharge/transfer orders.

Training can be found using the following link.  Please note that you will require your AHS username and login to access this training.

Connect Care "Street-Smarts"

Self-directed learning to cover important topics like inpatient chart sidebar use, problem list management, problem oriented charting. These are organized as a series of very short tips supplemented by 2-4 min online demonstrations. 

http://streetsmarts.connect-care.ca 

There are a number of strategies for insuring that admission orders on all new medical admissions are complete and comprehensive. Connect Care has admission order sets that can be used.  An alternative approach is to use the mnemonic ABC DAVID.

Each letter stands for a category of patient orders that should be written or at least considered with each admission, as follows:

A = Admit

• Starting the orders with the word Admit, instructs the nursing staff and all other personnel on the wards to carry out the orders which follow. 

• In most institutions all proceeding orders are considered invalid (e.g. the orders written in the Emergency Department). 

B = Because of

• The primary problem or diagnosis resulting in this admission 

C= Care of 

• The service and staff physician responsible for the ongoing care of this patient 

D = Diet

• Each patient needs a specific diet, ranging from NPO (nil per os or nothing by mouth) to DAT (diet as tolerated) 

• In course of the rotation, you will learn a number of other specific directions or restrictions related to diet. 

A = Activity

• Patient activity in hospital will range from AAT (Activity as tolerated) to strict bed rest. 

V = Vital Signs

• Vital signs normally include: 

  • Pulse (P), rate and rhythm (regular or irregular) 

  • Blood pressure (BP) 

  • Respiratory rate (RR) 

  • Temperature (T) 

• Routine vital signs are carried out once a shift. (q 12 hours) 

• This heading also includes related monitoring and nursing care orders to be considered such as: 

  • Daily weights 

  • Intake and output (I & O’s) 

  • Neuro checks 

  • Special equipment, positioning of the patient (slings, braces) 

I = Investigations

• There are a limited number of basic investigations which normally are carried out in all medical admissions, if they have not already been completed recently. These include: 

  • CBC (complete blood count) 

  • Lytes (serum NA, K, Cl, C02) 

  • Cr, urea (serum creatinine, urea) 

  • FBS (fasting blood glucose) 

  • U/A (urinalysis) 

  • EKG (electrocardiogram) 

  • CXR (chest x-ray) if the patient is 40 yrs of age or older, or there is a specific indication 

• All other investigations will depend on the patient problems identified during the Admission History and physical Examination, and recorded in the problem list, together with your plans to evaluate them. 

D = Drugs or Treatment

• There are no routine orders for treatment with medical admissions. 

• Most medical patients are maintained on one or more prescription medications for chronic illnesses, prior to admission. In general patients should stay on the same drugs, doses and dose schedules when admitted, unless there is a specific reason to change the treatment 

• The rest of the drugs you order will be determined by the specific patient care problems identified through the patient history and physical examination, and recorded in the problem list.