Patients’ Notes

There is a specific electronic admission template in CRS and a separate paper daily sheet which are universal across the ACCU.  When admitting a patient, please enter the date and time you saw them pre-ACCU, as well as the time they were ready for admission, and actually admitted, at the top of the form.  As we don’t yet have a computer at every bed space, print out your admission note and give it to the nurse at the bedside.  Any changes to the initial plan should be either added to the electronic record, which is re-printed, or written on the print-out.  In all cases, you are responsible for verbally communicating the plan/changes to the nurse looking after the patient.

Please write an update and management plan for each patient in their notes each morning.  In addition all procedures, as well as emergency treatment carried out during the day, must be documented contemporaneously.

Each patient will have a yellow weekly booklet.  This is where blood results, line, drains and tubes, care bundles, MRSA screening results and microbiology ward round notes are documented.  In addition to writing the daily sheet, ensure this document is up to date when reviewing a patient.  All significant microbiological findings, antimicrobial therapy and comments from the daily microbiology ward round (e.g. SOS drugs) must be clearly documented in this booklet.

After 72 hours admission, a pop-up dementia and delirium screen will appear in CRS for patients aged 75 and over.  Please do not simply click emergency override, unless it is an emergency.  Instead:

Ignore the 4AT & AMTS scores (not validated in the critically ill) and scroll down.  Complete the following:

  • “Does the patient have clinical diagnosis of Delirium?”  Yes/No (e.g. Yes if CAM-ICU positive)
  • “Does the patient have formal diagnosis of Dementia?”  Yes/No
  • “Has the patient been more forgetful in the past 12 months or has AMTS 0-8?”
    • Not Applicable
    • Critical / Terminal illness

All communication with other teams and with family members must also be documented.

A electronic transfer summary must be written prior to all discharges from the ACCU.  Similarly, a brief CRS discharge summary should be sent to the GP for any patients who die on the ACCU.