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SIGNOUT Pocket Card

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  • Very interesting presentation !!! Thank for sharing :-)) Bernard

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    SIGNOUT Pocket Card SIGNOUT Pocket Card Document Transcript

    • “SIGNOUT?” VERBAL SIGN-OUT (Horwitz, et al. 2007) Sick or OK, this is our sickest patient, and he’s S DNR? full code. Identifying Mr. Jones is a 77-year-old gentleman I data (one with a right middle lobe pneumonia. liner) General He came in a week ago hypoxic and G hospital hypotensive but improved rapidly with course IV levofloxacin. Today he spiked to 39.5°C and white count bumped from 8 to 14. Portable New events chest x-ray was improved from N of day admission, we sent blood and urine cultures. U/A was negative but his IV site looked red so we started vanco. Overall Right now he is satting 98% on 2 L NC O health status and is afebrile. If he becomes persistently febrile or Upcoming starts to drops his pressures start possibilities normal saline at 125 cc/h and have a U with plan low threshold for calling the ICU to and take a look at him because possible rationale sepsis. I’d like you to look in on him around To Do midnight and make sure his vitals and overnight T exam are unchanged. I don’t expect with plan, any blood culture results back tonight rationale so there is no need to follow those up. Any ? Any questions? questions?
    • ANTICipate for Written Sign-out (Vidyarthi, et al. 2006) Administrative Data □ Patient name, age, gender □ Medical record number □ Room number □ Admission date □ Primary inpatient medical team, primary care physician □ Family contact information New Information (Clinical Update) □ Chief complaint, brief HPI, and diagnosis (or differential diagnosis) □ Updated list of medications with doses, updated allergies □ Updated, brief assessment by system/problem, with dates □ Current “baseline” status (e.g., mental status, cardiopulmonary, vital signs, especially if abnormal but stable) □ Recent procedures and significant events Tasks (What needs to be done) □ Prepare cross-coverage (e.g., patient consent for blood transfusion) □ Warn of incoming information (e.g., study results, consultant recommendations), and what action, if any, needs to be taken that night Illness □ Is the patient sick? Contingency Planning / Code Status □ What may go wrong and what to do about it □ Using if/then statements □ What has or hasn’t worked before (e.g., responds to 40mg IV furosemide) □ Difficult family or psychosocial situations □ Code status, especially recent changes or family discussions