The document establishes guidelines for proper documentation in medical records to ensure effective communication between healthcare professionals and compliance with legal responsibilities, noting that orders must be clear, concise, organized, legible, and evaluated regularly for changes in patient condition. It outlines the roles and responsibilities of various professionals who can accept and document patient care orders, and provides standards for ensuring orders are appropriate, reasonable, and promptly questioned if issues arise.
this power point help new clinical pharmacist to start practice ,understand the concepts of clinical pharmacy and give them all the tools to give good care to the patient
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
2. To establish guidelines and the responsibilities
for various disciplines who depend on the
medical record as the primary tool for
communicating information to patient care.
To provide standards for uniform documentation
practice by all physicians.
To ensure competent records toward fulfillment
of medico-legal responsibility of physicians.
3.
4. Patient Care Orders are: the
physician prescriptions, or
authorization for the diagnostic or
treatment service to a patient.
5. Most Important Communication piece
Culmination of all skills (Assessment, Analysis,
Plan)
Initiates all care
Historical record; Sequence of events
Communication to all caregivers
Communication to lawyers
6. Entries may be made into the medical record by:
Physicians, Nurses, Pharmacists, RT, Dietician,
Care Coordinator, Special Ed Teachers, Dentists,
Midwives, Paramedic, Social Worker, Recreation
Specialist, Radiology tech.
Your entries communicate to all of these
professionals
7. The following health care professionals may
accept and document patient care orders:-
1. Professional nurses/ midwives,
2. Dieticians,
3. RT,
4. Pharmacist,
5. Physical/occupational/speech therapist,
6. Radiology technicians,
7. Dental therapist,
8. Orthopedic technicians,
9. Designated CT and MRI technicians.
8. If the individual authorized to accept patient care
orders believes that any orders fail outside
acceptable standards of patient care, or is
otherwise inappropriate, unreasonable, that
person must refuse to execute it.
They must promptly inform the physician why
they refuse the order.
If the order remains unchanged, the individual
should notify their supervisors, and a physician
at the next higher level.
9.
10. physicians order are documented in consistent
location with in medical record
Physicians orders include medication and non-
medication orders.
Must be written and signed by the physicians
before they can be executed, except in case of
V/O and T/O.
Shall be precise e.g.; PRN orders shall estate
the indication for administration of the drug.
11. Only forms approved by the Medical Records
Committee shall be used in the record
All entries must be legible with author clearly
labeled, with date(date-month-year sequence)
and time(24-hours clock system).
Every page shall contain patient’s name and
medical record number.
Who is responsible for this? YOU, and anyone
writing on the page.
12. Continuous; lines/space, if skipped, should be
marked through.
Made in black or dark blue ink.
Only approved abbreviations and symbols may
be used.
13. 1) Timely
2) Clear
3) Concise
4) Organized
5) Legible
Re-evaluate as frequently as required for patient
condition changes
14. A physician shall not change the orders or plan
of management of another physician, unless:-
1. Specifically requested or authorized by the
attending physician.
2. The chief of service deems it necessary,
urgent and in the patients best interest to do
so.
15. When an error occurs, a line should be drawn
through it and the word error written on the line
next to it. This is followed by name, title, date
and time.
Then, re-write proper information.
No correction fluid is to be used.
Don't use eraser
16. Use of identification stamp is encouraged.
When stamp is used, a signature must still be
present above the stamp.
19. The procedure:
1. Listen to the order,
2. Repeat the patient’s name, file number, room
number, diagnosis and complete order back to
the physician to ensure accuracy.
3. Record the order,
4. Record the date and time,
Sign your name and badge number, before the
end of the next calendar day after the order was
given.
20. V/O are appropriate in the following situations:-
1. Emergency.
2. If practitioner placing the order is physically
unavailable and order has urgency.
3. If physician is performing a procedure.
Must be signed, dated and timed within 48 hours
(except Med orders and restraint orders which
are 24)
21. Cannot be used for:
1) Chemo,
2) DNR/Code Status;
3) Post OP,
4) PCA;
5) Hyper- alimentation;
6) Withdrawal of life support;
7) Heparin;
8) Initial parenteral orders of narcotics
22. Admit to : Ward, ICU, or preoperative room.
Diagnosis: Primary Diagnosis, Other Diagnoses
Indication and Intended operation.
Condition: Stable
Nursing Vital Signs:
Frequency of vital signs;
Input and output recording;
Neurological or vascular checks.
23. Notify physician if blood pressure <90/60,
>160/110; pulse >110; pulse <60; temperature
>38.5; urine output <35 cc/h for >2 hours;
respiratory rate >30.
Activity level (precautions, bed rest, elevation of
bed, weight bearing restrictions, rotation bed,
bathroom privileges )
Allergies: No known allergies
Diet: NPO
24. Medications:
Antibiotics to be initiated immediately
preoperatively; Additional dose during operation
and 1 dose of antibiotic postoperatively.
Must be on Doctors order form or other
approved form (Heparin, Lovenox and Protonix)
Include all Drug; Strength; Route; Frequency
All strengths and volume in metric system
25. Parameters required for PRN (fever, pain)
only one range of dose per statement,( eg;
Morphine xx - xx every 4 hours for pain)
All medication orders must be individually
reordered following surgery. “Resume” orders
are not acceptable
“Resume Home Meds” cannot be used.
Any ambiguous or illegible order will be required
to be re-written prior to filling the medication
26. All home medications brought into the hospital
to be utilized by inpatients will be verified first by
pharmacy as the proper medication prior to
administration.
27. Labs and Special X-Rays:
Electrolytes, BUN, creatinine, INR/PTT, CBC,
platelet count, UA, ABG, pulmonary function
tests.
Chest x-ray (if >35 yrs old),
ECG (if older then 35 yrs old or if cardiovascular
disease).
Type and cross for an appropriate number of
units of blood.
28.
29. Transfer:
From recovery room to surgical ward when
stable.
Vital Signs: q4h, I&O q4h x 24h.
Activity:
Bed rest; ambulate in 6-8 hours if
appropriate.
Incentive spirometer q1h while awake.
IV Fluids:
IV D5 LR or D5 1/2 NS at 125 cc/h
30. Diet:
NPO x 8h then sips of water.
Advance from clear liquids to regular diet as
tolerated.
Medications:
1. Cefazolin 1 gm IV q8h x 3 doses;
2. Meperidine 50 mg IV/IM q3-4h prn pain
Laboratory Evaluation: CBC, Chest x-ray in AM
if indicated.
31. Post-operative, pre-admission, pre-
procedures orders are valid for 30
days in the event the surgery,
admission, procedure is delayed, and
as long as patient’s conditions
unchanged.
32. Are preprinted sets of instructions for the patient
care which can be initiated by a nurse in the
absence of physician order.
Amendment may be made to the pre-printed
orders by a physician in writing, verbally or over
the telephone.
Must be signed by the attending physician within
the next calendar day.
33.
34. 1) Its not so easy. Slow down. Re-read what you
wrote. Ask for help.
2) Watch unapproved abbreviations
3) 5 Basics (Pt, drug, dose, route, time)
4) PRN need a rationale
5) Don’t use two ranges in same order (20-40 mg
q 4-6 hours)
6) Legibility