Possible reasons for condition to be monitored:
Fall, Fever, Vomiting, Wounds, Skin condition, Post operative care, Diarrhea, Other
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Identify condition in need of monitoring.
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Contact PM, PD or Oncall (after business hours) for further direction and set up of service.
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Detailed description of condition along with steps to monitor/treat and requirements for notification will be added to the body of the service.
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Staff will create a resident note (medical entry) under the +More section in Rtask describing all items listed in #3. Staff will send an Rtask message to all staff: “JB has new medical entry, please read.”
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Staff will check complete on the service created only after completing a medical entry note pertaining to the medical condition monitor. Details will not be added to the service notes, but only in the detailed medical entry note.
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Once the condition is healed or no longer relevant, staff will contact their PD or Oncall to discontinue the service. Staff will then document details of discontinuation of medical condition monitor in a final medical entry.
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All information pertaining to the medical condition monitor can be found in one central location of medical entry notes.
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Any PRN medications needed/administered will be documented in the +More ‘administer PRN medication’ section of Rtask along with being documented in the medical entry.
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Staff will fill out an information report as needed.
Medical Condition Monitor
Example: Medical Condition Monitor Service
On 8-26-15, Joe fell when walking to his bedroom. Joe landed on his right hip and elbow; he did not appear to hit his head. A full body check was competed and Joe does not appear to have any bruising, injury or pain at this time.
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Staff will monitor Joe for the following and document all information in a medical entry note:
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Full body check for bruising or injury-if injury is found, staff will contact physician, PD or oncall for further direction
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Pain - If pain is present, staff will administer PRN per physician order and document in PRN medications along with medical entry