Latrobe Regional Hospital

(LRH)

<Admin>   <Index>

 

 

About

Comms

Admin

 

 

 

 

 

 

About LRH

<LRH>

 

Latrobe Regional Hospital

-  Princes Hwy

-  Traralgon West VIC 3844

-  PO Box 424

-  Phone: (03) 5173 8000

-  Fax: (03) 5173 8444

 

 

-  Major provider of acute secondary hospital services for whole of Gippsland

-  Services 70,000 in Latrobe Vallet

-  240,000 residents in conjunction with other health services in Gippsland

-  257 beds

-  General & speciality medical & surgical services

-  Maternity, mental health & paedatric services

 

Blood Bank

-  Contact 38297

-  Regional stock for Gippsland at LRH

-  2+ units O negative & 4 units platelets on standy

-  FFP on site (frozen) & takes 30min to supply

-  Some products require T/F from Melb & take 4hrs+

-  Recombinant Factor VIIa requires executive approval

 

 

 

Admin

<LRH>

 

 

Operation Reports

 

D/C Sum ---- Scripts ---- Consults

 

Med Record ---- Admissions

 

Ward Lists ---- Requests

 

Death

 

Med Charts --- New Ward

 

Work Cover

 

 

 

Operation Reports

<Admin>

 

Features

-  SURGbase LIVE from start menu

-  Search for pt in Obstetric list

-  Add new patient if not in list

-  Select Female pelvis

-  Select Caesarean section 16522 – need to amend printed report

-  Dump text from template

-  Amend details as necessary

-  Clear urine in IDC pre & post op

-  Repeat vs primary

-  Uterus empty

-  Closure method

-  Ovaries & tubes

-  EBL

-  Print x3 copies

-  1 copy to surgeon

-  2 copies to file

-  +/- print a copy for self if performed surgery

-  Sign all copies

 

 

 

Discharge Summaries

<Admin>

 

Features

-  Summary of pts admission

-  Written for LMO = handover to GP

-  Consultant for F/U in out-pt

-  Info for next admission

-  Completed for within 24hrs of D/C

-  Every pt

-  Discharged

-  Death

-  D/C against medical advice

-  Absconding

-  If not done placed file in Drs box

 

Procedure

-  Gynae D/C summaries only

-  Obs D/C summaries completed by Midwives

-  Hand written

-  Sign all D/C summaries

 

Content

-  Add Ix as relevant

-  Most recent, relevant

-  F/U plan

-  Typically w LMO

-  +/- out-pt clinic

-  Presenting S/S

-  Include Obs & PE

 

 

 

Consults

<Admin>

 

Prepare

-  Have pt notes, med chart, recent results

-  Know

-  Why consult?

-  What consult usual tests are?

-  Sell the case

-  Document in the notes

-  Conversation & result

-  Attempt to contact if unsuccessful

 

ISBAR

-  Identify

-  Who talking to

-  Yourself: name, position, location

-  Pt: name, age, sex, location (ward & bed)

-  Situation

-  The reason I am calling is..

-  If urgent say so

-  Background

-  Relevant Hx, Ex, Ix, Mx

-  If urgent: obs, Mx

-  Assessment

-  What is going on

-  Request

-  Id like you to r/v this pt

-  Your opionion on Mx, Ix

-  Help urgently

 

 

 

Medical Record

<Admin>

 

Procedure

-  Correct pt file

-  Legible in black/blue

-  Each page labeled w Bradma

-  Date & time all entries

-  Record

-  Date: dd/mm/yy & time

-  Team: discipline/speciality & members

-  Frequency

-  Acute pts x1 entry/day+

-  Sub-acute pts x1 entry/week+

-  Errors ruled through w single line & signed +/- explanation

-  Dont leave gaps or empty lines

-  Rule though gaps

-  Sign all entries w pager number

-  Student entries countersigned

 

Entries

-  Ward Rounds

-  New Admissions

 

 

Ward Rounds

<Medical Record>

 

-  Upto date

-  Recent results (folder if applicable)

-  Copies of imaging

-  Consults & recommendations

-  Overnight

-  Nursing input

-  SOAP

-  Subjective

-   Current state

-   HPI +/-

-   New S/S

-  Objective

-  Obs: HR, BP, RR, O2Sat, Temp

-  Team notes

-  Chest +/- abdo

-  Chief complaint related

-  Assessment (Impression)

-  Dx +/- complications

-  Issues

-  Ongoing Mx

-  New onset problems

-  Waiting for consults/Ix

-  Allied health

-  Plan

-  Ix times

-  R/V by ..

-  D/C (or date)

-  Clear plan for nurses/allied health

-  Alert nurses to plan if not in attendance

-  Fill in requests on the go

-  Reg/Consultant to sign CT/MRI slips

-  Record consults & results to chase

 

 

 

Admissions

<Medical Record>

 

-  New General Admission

-  Labour Admission

-  SCN Admission

 

Features

-  All admission need: date, time, name, position, role

 

 

 

New General Admission

<Admissions>

 

-  Open: x yr old male presents w..

-  HPI w detail: SOCRATES..

-  Known to Dr

-  Recent admissions

-  From home/NH/transfer..

-  Sx Pts

-  Last meal

-  Tetanus if skin injury

-  PMH: w results & dates

-  Sx Pts

-  GA & reactions

-  Meds & Allergies (include reaction)

-  Family & Social Hx

-  Systems R/V

-  DM, AMI, Stroke, HTN, COPD

-  Ex

-  General: distress, unwell..

-  Vitals

-  Systems

-  Comment on analgesia

-  Ix

-  Bloods, X-rays

-  Impression

-  Working Dx

-  2o to if known

-  Note if stable

-  List complications

-  Plan

-  Admit under..

-  Ix

-  Mx

-  R/V & Consults

-  Sx Pts

-   Bloods: G&H

-   Abx: dose, freq

-   Fluids

-   Fast from when

-   For OT?

-  Alert nurses

 

 

 

Woman in Labour Admission

<Admissions>

 

-  Female x yrs old GxPx at x/40 weeks gestation w..

-  HPI

-  Details of reason for R/V

-  Obs Hx

-  GxPx

-   G1 = year + location, gestation, labour (SROM vs ARM, IOL), type of birth (NVB, Assisted, LUSCS), complications, weight of child

-   Include M/C (year, gestation, type, Mx ie: D&C..), TOP, FDIU..

-   G2..

-   Gx = current at x/40, EDD, LMP

-   Under care of Dr..

-   Blood group, antibodies

-   Vitamin D levels +/- Rx

-   Hb level +/- Rx

-   Rubella immunity, HBV/HCV/HIV/Syphilus serology

-   Last US: placental location, size (EFW), +/- AFI, SD, position

-   Complications during pregnancy

-  Gynae Hx

-  Pap smear Hx

-  +/- menstrual Hx

-  PMHx

-  BMI

-  Meds, allergies

-  Examination

-  Vitals: esp BP

-  Abdo exam

-   Palpation

-   +/- VE & bimanual

-   +/- Speculum

-  Impression

-  Plan

 

 

 

Special Care Nursery (SCN) Admission

<Admissions>

 

-  Indication for admission + age

-  +/- why T/F

-  Maternal Hx

-  Age

-  Gravida, Para

-  Blood group

-  GBS status

-  Immunisations: Hep B/C, HIV, Rubella, Symphilis

-  Previous obstetric Hx

-  PMH

-  Meds, drugs, addictions

-  +/- paternal Hx

-  Pregnancy details

-  Birth details

-  DOB

-  Gestation at birth

-  Exam

-  Weight, length, HC

-  Alertness, gross motor, Moro

-  Movements, spine, fontanelle

-  HR, RR, Temp

-  Murmur

-  Abdo, genitalia, anus patent

-  Dysmorphisms, umbilicus

-  +/- = new born examination

-  Issues

-  Mx

-  Feeds +/- BSLs

-  Ix: SBR

 

 

 

Ward List

<Admin>

 

Features

-  Use

-  Select appriate shift ie: Wednesday night

-  Worksheet 07

-  Print

 

 

 

Requests

<Admin>

 

Bloods

-  Requests printed via Bossnet

-  Ensure printed on one side only

-  Ensure blood bank tubes are hand written

-  For add ons ring to confirm possibility then print request

-  Contact porter to take once completed

-  For path collection complete & leave in Path drawer on ward

 

Imaging

-  Requests printed via Bossnet

-  Request taken to radiology in person

-  Given to reception if for next available

-  Given to radiographer if urgent

 

 

 

Patient Death

<Admin>

 

-  Pronouncing death

-  Death Certificate

-  Coroners Case

 

Pronouncing Death <Up>

 

Features

-  Certify death

-  Patient may be unknon to you

-  Be aware of coroners cases

 

Procedure

-  Physcially Examine

-  Pupil response: fixed dilated

-  Heart sounds: absent

-  Breath sounds: absent

-  Pulse: absent at carotids

-  Document findings in notes

-  As above

-  Date & time

-  Declared deceased

-  Notify consultant

-  Notify family 

-  D/C summary needs to be done

 

Death Certificate (Non-coroners) <Up>

 

Procedure

-  Certify/pronounce death

-  Green form

-  Cause of death

-  Cannot use cardiac or respiratory arrest

-  Include registraton number

 

Coroners Case <Up>

 

Features

-  Cases which require investigation & autopsy by the coroner

-  Reportable deaths are

-  Unexpected, unnatural or violet deaths

-  Directly or indirectly from an accident or injury

-  Occurred during a medical procedure or following a medical procedure where the death is or may be causally related to the procedure and a registered medical practitioner would not, immediately before the procedure was undertaken, have reasonably expected the death to occur

-  Pt of unknown identity

-  Deaths in custody or care (incl mental health)

-  Patient must be left as is: no tampering

 

Procedure

-  Certify/pronounce death

-  Inform coroners office

-  Medical deposition online

-  www.coronerscourt.vic.gov.au/meddep

-  Print copy for pt file

-  Coroners office informs Police to attend once submitted

-  Family/staff to complete Statement of ID

-  Copy the medical records for hospital as notes will accompany pt to coroners

-  D/C summary needs to be done

 

 

 

Med Charts

<Admin>

 

Content

-  When canceling orders

-  Sinus wave through order

-  Sign, date

-  Reason why ceased

-  If opiates PRN anti-emetics

-  Always check allergies prior to writing med

-  Use generic names

-  Preceding 0s but not trailing (0.5, not 5.0)

-  Rewrite orders rather than alter

-  Phone orders

-  Must confirm with second nurse

-  Sign order when possible

 

 

 

New Ward

<Up>

 

- Introduce to staff (record names)

-NUM

-Nurses

-Pharmacists

- Locations of

-Amergency assist buttons

-ALS cart

-Patient notes, bed charts

-Pathology & Imaging forms

-Fax/electronic..

-Access to images

-Other forms: consent..

- Protocols

- Bosses: who, what like, preferences

- Pager numbers

- Computer access

-Passwords

-Programs

-Patient information

-PACS

-Discharge summaries..

-Printer

 

 

 

Work Cover

<Up>

 

-  Injury/illness must be directly linked to work place

-  ED: attendance certificate --> 14/7 modified duties

-  GP: dates as required

-  Illegal to cover under Medicare if work related injury

 

 

 

Communications

<LRH>   <Index>

 

Emergency 333

 

 

Paging

Contacts

 

 

 

General

-  External line: 0

-  Switch: 99

-  Co-ordinator: 8054

-  Extensions: last 4 digits

-  Page: 3 then pager number

-  Prefix: 5173

-  To transfer calls: transfer then 322 then last 2 digits of room number, wait for ring tone, hang up

 

 

 

Paging

<Comms>

 

Features

-  Used for contact throughout hospital

-  Delete all pages prior to starting shift

-  Ensure battery not empty & secure

-  Loss of power = loss of pages

-  Ensure correct time & date

 

Procedure

- Alert Page

-  Dial 3 then pager number

-  Wait for ring tones

-  Hang up

-  Sends message Please call xxxx

- Text Page

-  Pager number

-  Text message

-   Ensure return pager number/extension

 

 

 

Contacts

<Comms>

 

Emergency 333

 

General

 

Medical ---- Surgical ---- A/H

 

Wards ---- Services ---- Fax #s

 

 

 

General

<Contacts>

 

-  Co-ordinator: 38054

-  Booking Office (OT): 38028

-  Ordelry: 32702

-  Cafe: 38187

 

Medical <Up>

 

-  Med Reg: 326267 (Nina)

 

Surgical <Up>

 

-  GS1:

-  Ortho:

-  Paeds:

 

A/H <Up>

 

-  Med Reg:

 

Wards <Up>

 

-  Tanjil

-  Tara

-  Thomson

-  Drs: 38244

-  MW: 38211

-  ANUM: 38146

-  Ward Clark: 38140

-  SCN

 

Services <Up>

 

-  Switch: 99

-  Blood Bank: 38297

-  Rad: 38080, 38089

-  Path: 38121

-  Pharm: 38588

-  IT Help:

 

Fax #s <Up>

 

-  Prefix for LRH 5173..

-  Rad:

-  Path:

-  Endoscopy:

-  Cath Lab:

-  SAAS: