Recently there have been several PSRs filed in reference to IM service/teams not completing the patients LST promptly following admission, specifically there have been occurrences where the patient has undergone a procedure without an updated LST on file.
Reminder when admitting a patient, your work flow should be:
Evaluate the patient and ensure they are getting admitted to appropriate level of care
Place PSO order
Place and plan for later the appropriate order set
Place separate order informing nursing staff to activate the order set when patient arrives to floor
THEN LST MUST BE COMPLETED at that promptly right after completing order set tasks.
LAST, should then be notes and IPASS and other tasks as needed.
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***The admin things and especially the LST are critical to have right when someone is admitted because all nursing staff, other services, etc. must know the patients code status right away in the event of some unforeseen emergency.***
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If assuming care of a patient when transferred from another service or the ICU, you need to have a separate and NEW conversation with the patient regarding their code status and complete a NEW LST. Even if nothing has changed with their code status from the time of their admission. Whenever a patient changes teams or levels of care, there must be a new LST documented.
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***AND remember if the patient is anything other than full code, the LST MUST be forwarded to the Attending for signature.***
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