1. Patient's primary diagnosis
This should include any current or pending diagnosis that is affecting the care of a patient, including mental health diagnoses. This will help in understanding the needs of the patient as well as provide a basis for further care.
2. Current medications being taken
It is essential for clinicians to know what medications are currently ordered and administered to a patient, as well as any changes in dosage or frequency.
3. Recent change in patient status or vital signs
Any changes in the patient's health status or vital signs should be reported to other team members so that proper care can be provided.
4. Recent laboratory results and pending tests
It is important to review any new lab results as well as any pending tests or treatments that may be necessary for the patient's care.
5. Allergy information
Providing this information will help avoid any serious allergic reactions to certain medications or treatments.
6. Plans for the current shift (medications, treatments, activities)
Knowing the planned care for a shift helps to ensure that all team members are on the same page and can provide appropriate care.
7. Results of any recent radiology studies/imaging reports
It is important to be aware of any results from imaging studies as they may lead to changes in the patient's plan of care.
8. Specialized equipment used by patient or inpatient care plan
This information is necessary for proper care and monitoring of the patient.
9. Infection control concerns related to the patient's condition
Knowing any potential infection control concerns can help limit the spread of illness and provide proper care for the patient.
10. Other notes from previous shifts
Any additional notes from the previous shifts can provide valuable insight into the patient's care plan and any changes that may have been made. This will also help ensure continuity of care for the patient.