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Nightly Routine

Quick Check:

  1. Meds
  2. Return Passes, UA,  Breathalyzer, Room Check
    1. Also check that vitals are qmonth
  3. Email, MARS, PRN/Missed Meds
  4. Bed Checks
  5. End of NOC
  6. Weekly Notes, 72 hr observations
  7. Morning wake up (med safe)
  8. UA (courier), Weights, Meds
  9. New admits
    1. vitals
    2. meds
    3. 72 hour notes
  10. Other
    1. early pass & “S” note
    2. Cleanup pass book
      1. scan passes for the wknd
    3. RME

 

 

Work Distribution:

NURSE 1: Blue, MARS, 2nd Floor, RME, missed meds, 2 hr sheet,

NURSE 2: White, environmental rounds, emergency roster, PRNs, UA-tox, census, tracker return

NURSE 3: Rounds, passes, VS input, early S-notes, fall notes, observations, seizure notes

BEGIN SHIFT

    • come in 30 minutes early
    • check for unverified orders & PRN effectiveness (up ’til 0600)
    • printout missed meds list

01 Shift Change Report

  • any recent med changes?
  • write down who is on PASS tonight & needs tox
  • PASS returning fill out the back (ask if they already have a copy)
  • give meds
  • weekly room inspection & weekly urine tox (not nurses’ discretion)
  • 2200 bed check
  • who has appointments and/or needs PASS
  • check missed meds list/PRN effectiveness
  • collect samples

 

MID-SHIFT

  • return from PASS narrative notes
  • audit
    • what week is Vet on?
    • weekly notes
    • treatment plan done within a week?
    • fall notes
    • pt. education
    • acknowledge receipts (‘select patient > process info >> next [shows as a hand icon]’)
    • clinical reminders
  • SCHEDULING
    • note who is going to be missed on PASS & don’t book
  • RME (2nd & 3rd floors)
  • unpack/order supplies
  • track group attendance for the day
  • Weekend Checklist to email?
  • Veteran pass list

 

END OF SHIFT (MORNING)

  • print and email End of Shift report to Elaine & Ethel
    • Elaine is emailed the report, Ethel gets a printout in her binder
  • PRINT
    • missed med report
    • print 2 hr check
    • Kardex
    • BCMA due list report
  • text Lori from lab for samples pickup
    • Saturdays drop at MV
  • PRN effectiveness
  • put out the log books
  • clean
    • empty trash (weekends)
    • clean
  • water for the pitchers
  • give report
  • double check missed meds / PRN
  • U-tox 1000 random list orders
    • add UA for certain people

 

SIDE PROJECTS

  • WEEKEND CHECKLIST (PASS+Meds+Weights+WkndProgram Tracking)
  • CPRS templates

NOTE TITLE ASSIGNMENTS

  • Weekly notes = “ASPIRE  <NURS/ASPIRE/WEEKLY>”
  • 72hr (new admit) =”ASPIRE  <PT ED/ASPIRE/PATIENT HEALTH EDUCATION>”

TYPING END OF NOC SHIFT REPORT due @ 0500

  • When doing End of NOC shift report assignments for the incoming NOC shift later that night, just assign one NOC nurse on “Blue Team” and the other NOC nurse on “White Team”

CLINIC AVAILABILITY REPORT

Here is the directions to printing out the Clinic availability report/ what veterans are in what class.

  1. Sign into Vista.
  2. ^DIS
  3. 9 display Clinic availability report.
  4. Choose the groups for that day based off of the Veteran Schedule/Calendar
  5. Copy all the classes.
  6. Paste them into Word
  7. Clean up the pages, so there is one class per page. Take off everything but the date, class, schedule slots, and Veterans names.
  8. Print these pages out. (Make sure it is not in landscape when you print.)
  9. Staple the page to a sign in sheet and put them into provider boxes by the nursing boxes in the nursing station.

 

LAB COURIER PICKUP

For specimen pick-up during normal business days please call the VA transportation office at x7506.

The transportation drivers leave the VA at 0830 and 1pm.

For STAT deliveries (during non-business hours), call:

(636) 561 2518  account # 833

Also, please let me know if you need to access the stat delivery courier.

 

 

How to Print Current Med List

  1. Go to Reports tab > Health Summary > Pat.Medication Calendar
  2. You can actually get it by writing a new note and choosing the title, “Medication Reconciliation” under Pharmacy. It will automatically bring up the current meds and then you can just cut and paste it into Word for the Veteran. However, make sure to change the title to “Nurse Narrative” if you are writing a note. Don’t forget to keep the patient info private.

 

 

 

Nursing SOP 04Jul2014

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