How to read this week
Week 1 is the mechanics of an admission. From the moment a patient arrives, the AGACNP produces a sequence of written artifacts — the H&P, the admission orders, the progress note, the procedure note, and the discharge summary — and presents the patient to the care team in a matter of minutes. The chapter (85, Hospital Admission Considerations) is organized around those documents, plus prescriptions and the rules that govern the ICU and the electronic medical record.
What you write
- History & physical examination
- Admission orders
- Progress note (SOAP)
- Procedure note
- Discharge summary
- Prescriptions
Each feeds the next: the H&P informs the orders, the orders inform the progress note, and the progress note becomes the discharge summary.
Where the documents live
- Patient presentation during rounds
- ICU admission & discharge guidelines
- Electronic medical record (EMR)
These rules govern how fast, where, and how safely the written work happens.
Your reading map
| Topic | What it covers |
|---|---|
| History & physical examination | Identifying data → chief complaint → HPI → PMH/PSH/meds/allergies → family/social history → review of systems → physical exam → assessment/diagnoses → plan |
| Admission orders | The “A.D.C. VAAN DISSL” mnemonic — 12 letters covering level of care through laboratory studies, plus consults |
| Progress note | The SOAP format — subjective, objective, assessment, plan — for the daily note |
| Patient presentation | A brief, concise oral report for rounds — less than 2–3 minutes per patient |
| Procedure note | Nine components documented whenever an invasive procedure is performed |
| Discharge summary | Fourteen components, from date of admission to the list of who gets copied |
| Prescriptions | Required elements, scheduled-drug rules, and the “dangerous abbreviations” to avoid |
| ICU admission & discharge | Example conditions by system, and the two reasons to move a patient out |
| Electronic medical records | Patient focus, template hygiene, safety, and productivity |
A good admission is a written one. Every fact the AGACNP gathers lands in one of the documents; every document feeds the next. Miss a component in the H&P and the orders are blind; miss a component in the discharge summary and the next provider inherits a gap.
The numbers worth carrying in
Five documents, counted
How many enumerated components the reading assigns to each document. Hover a bar for its contents.
The Admission
The admission rests on two documents: the history and physical examination and the admission orders. The H&P is the AGACNP's own assessment — never just a copy of the chart.
- It should be concise, thorough, and focused on the individual patient.
- Information may come from previous H&Ps (e.g., a consult) — but always confirm chart information with the patient, or note that it is from another source (caregiver or family member) and unverifiable.
- Always include your own physical findings, impressions, and differential diagnoses — even if they differ from what the chart or records previously stated.
Who the patient is
- Patient's name, age, race, gender
- Informant — self, relative, friend, significant other
- Reliability of the informant
The reason for admission
The current problem or reason the patient is being seen by the AGACNP.
State it in the patient's own words, with quotations, and (if possible) based on the patient's condition.
History of present illness
Describe the complaint using OLD CARTS or PQRST + 3 As; arrange events in chronological order.
Add related history: previous treatments, previous diagnostics (with pertinent positives/negatives), and risk factors.
Past history & current agents
- PMH — major past diseases (HTN, MI, PUD, DM, asthma, cancer, CVA/TIA, bleeding, others); past hospitalizations with specifics
- PSH — past surgeries with approximate dates/years
- Medications — prescribed, over-the-counter, vitamins/supplements/herbal
- Allergies — medications, foods, environmental, latex — and the reactions observed
Context around the complaint
- Immunizations — influenza, pneumococcal, pertussis, tetanus; hepatitis, meningococcal, others
- Family history — medical issues of blood relatives; alive or expired (with cause of death)
- Social history — ETOH (drink size, number/day, years); smoking (ever/current/quit, years, pack-years); marital status and home support; employment and occupational exposures
13 systems, by symptom — not diagnosis
General · Skin · HEENT · Respiratory · Cardiovascular · Hematology · Gastrointestinal · Genitourinary · Gynecologic · Endocrine · Musculoskeletal · Neurologic · Psychiatric.
Listed by symptoms, never by diagnoses.
Head-to-toe, appropriate to the population
General appearance (age, gender, race, height/weight, ill or malnourished) · Vital signs (temperature, pulse, respirations, BP, oxygen saturation, pain, weight/BMI) · HEENT · Neck · Chest · Heart · Breast · Abdomen · Genitourinary · Rectal · Musculoskeletal · Peripheral vascular · Neurologic (mental status, cranial nerves, motor/sensory, DTRs).
Diagnosis first, then the plan
- Assessment/diagnoses in order of priority — use diagnosis, not symptoms; include differentials with reasons that support or exclude
- Plan — a therapeutic plan for each problem, plus planned labs, radiologic tests, studies, medications, and consults
Two mnemonics for the HPI
Eight classic elements
- Onset — when did it start; what brings it on
- Location of the pain/complaint
- Duration
- Characteristics — stabbing, gnawing…
- Aggravating factors — what makes it worse
- Relieving factors — what makes it better
- Treatment — what has relieved it
- Severity — preferably on a 1–10 scale
Eight alternate elements
- Provocative factors — what brings it on
- Quality of the pain/complaint
- Radiation
- Severity — preferably 1–10
- Timing — when does it occur
- Alleviating factors — what makes it better
- Associated factors — other conditions/feelings/life events at the same time
- Aggravating factors — what makes it worse
| Letter | Component | What to specify |
|---|---|---|
| A | Admit / attending | Level of care and service. |
| D | Diagnosis | Admitting diagnosis and procedure (if the patient is postoperative). |
| C | Condition | Stable · critical · other (e.g., guarded, improved). |
| V | Vital signs | Frequency and specific parameters (e.g., pulmonary artery catheter readings, intracranial pressure). |
| A | Activity | Bed rest · up with assistance · bathroom privileges. |
| A | Allergies | Any known or perceived allergies. |
| N | Nursing procedures | Preparations (enema, scrubs); respiratory care (IPPB, incentive spirometry, ventilator settings); dressing/wound care; parameters to notify the MD or AGACNP. |
| D | Diet | NPO · clear liquid · soft/regular. |
| I | Intake/output | IV solution and rate; I/O every shift including drains/tubes (Foley, NG tube, endotracheal tube, arterial line/PA catheters). |
| S | Specific medications | Routine (home) medications as appropriate, plus inpatient medications. |
| S | Symptomatic medications | PRN medications (pain medications, sleeping pills, laxatives). |
| L | Laboratory / diagnostics | Blood work specific to specimens (e.g., lumbar puncture, urinalysis) with times as applicable; EKGs; X-rays; other studies. |
| + | Consults | Provider, service, reason for consultation, time the consultant was notified and by whom. |
Parameters that trigger a call to the MD or AGACNP
The reading's examples of findings that must be reported. Three are numeric thresholds; two are qualitative. Hover a bar.
Identifying data: John Doe, 72, Caucasian male; information obtained from the patient, who appears reliable. Chief complaint: chest pain for 2 days.
HPI: history of MI 5 years ago with a cardiac stent placed at the LAD at that time; now intermittent, substernal, nonradiating pressure first noticed 2 days ago after mowing the lawn, lasting 1–2 min, rated 6–7/10, described as a “squeezing pressure” around the middle of the chest, relieved by resting a few minutes. He denies dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Symptoms recurred 2–3 times with exertion; in the ED one episode was relieved with 1 SL nitroglycerin. ECG shows ST changes in the inferior leads; labs pending.
PMH: MI 2000 s/p stent; HTN; hyperlipidemia; NIDDM. Denies CVA, PUD, renal disease. PSH: coronary stent 2000; hernia repair 1997.
Medications: ASA 81 mg daily · Atenolol 50 mg bid · Altace 5 mg bid · Glucophage 500 mg bid · Glyburide 5 mg bid · Lipitor 20 mg daily · multivitamin daily.
Allergies: PCN (rash) and codeine (severe nausea/vomiting). Immunizations: pneumococcal vaccine 3 years ago.
Family history: father expired at 50 of MI; mother expired at 72 with breast cancer; two living brothers, both with CAD/MI before age 50. Social history: 50 pack-year smoker (quit 5 years ago); 1–2 beers on weekends; retired engineer.
Exam (excerpt): 6'1", 190 lb; temperature 98.6 °F; HR 88 RRR; respirations 12; BP 130/70. Heart: sinus rhythm without ectopy, PMI 5th ICS, MCL, no extra heart sounds or murmurs. Peripheral vascular: 1+ to 2+ pretibial edema bilaterally; 2+ pedal pulses bilaterally. Neurologic: alert/oriented × 4.
Assessment: chest pain — with prior MI and ECG changes, most likely cardiac; cholelithiasis possible but unlikely. HTN controlled; diabetes controlled; hyperlipidemia.
Plan: standard nitroglycerin drip titrated to chest-pain relief · STAT CBC, BNP, troponins now and Q 8 hr × 3 · BMP, PT/PTT, lipase, amylase, CXR · STAT chewable ASA 81 mg × 4 · admit to CCU · cardiology consult STAT for probable urgent angiogram/PTCA.
Documentation
Three notes carry the stay forward: the daily progress note (SOAP), the procedure note whenever something invasive happens, and the discharge summary that closes the loop. Filter to the one you need.
The five-part frame
- Date / time / service
- Subjective — how the patient feels; complaints in direct quotations; focus on the past 24 hours
- Objective — appearance, vital signs, I/O, exam changes, labs
- Assessment/diagnosis — per problem, with status (active/resolved)
- Plan — per problem
What to record under O
- General appearance
- Vital signs
- Intake/output
- Physical exam — emphasize changes from previous exams
- Laboratory/test results and current medications
Labs to track — and flag
- Prothrombin time (PT) · partial thromboplastin time (PTT)
- Amylase · albumin · calcium (Ca) · magnesium (Mg)
If a result is abnormal, mark whether it is up (increased) or down (decreased) from the patient's previous results.
Document every invasive procedure
Written whenever an invasive procedure is performed — e.g., lumbar puncture, thoracentesis, chest tube placement.
Begin with date/time (specify the time of the procedure) and the procedure performed, plus the indications.
Consent and labs first
- Patient consent — document that the patient/representative was informed of risks and benefits (most hospitals require a separate signed consent)
- Laboratory tests — relevant results (e.g., INR / CBC)
The description block
- Briefly describe the procedure
- Sterile preparation · patient position
- Devices used / implants placed (including sutures — number, material)
- Anesthesia/sedation used · location · drains · outcome
Complications, EBL, disposition, specimens
- Complications & estimated blood loss — if EBL is more than “minimal,” estimate the actual amount
- Disposition — how well the patient tolerated the procedure
- Specimens/findings — findings, opening pressures, appearance, method of collection, time sent to laboratory
The identity block
- Date of admission · date of discharge
- Admitting diagnosis · discharge diagnosis (primary + secondary)
- Attending physician / AGACNP / consultants (names)
- Procedures — surgery and invasive diagnostics (e.g., lumbar puncture, angiogram)
The narrative & the send-off
- Brief history + pertinent PE + lab data; hospital course (treatments, medications, response)
- Discharge condition (improved / deteriorated / unchanged); disposition (home, SNF, other hospital) and who assumes care
- Discharge medications (doses, scheduling, refills) with reconciliation · instructions & follow-up (appointments, diet, activity) · problem list · consultants/PCPs to copy
A progress note summarizes developments during hospitalization, problems that remain active, the plans to treat them, and discharge/transfer plans (as appropriate).
- Date / time / service.
- Subjective data — how the patient feels; include complaints, preferably in direct quotations; focus on the past 24 hours.
- Objective data — general appearance; vital signs; I/O; physical exam (emphasize changes from previous exams); laboratory/test results (current medications, PT, PTT, amylase, albumin, Ca, Mg, and other results as appropriate). Mark abnormal labs as up or down from prior.
- Assessment/diagnosis — for each problem, including status (active / resolved); evaluation of the data and conclusions drawn.
- Plan — for each problem: changes/additions to orders; new labs/tests/medications; disposition (discharge/transfer plans).
| Component | What to document |
|---|---|
| Date / time | Specify the time of the procedure. |
| Procedure | List the procedure performed. |
| Indications | The reason the procedure was necessary. |
| Patient consent | Patient/representative informed of risks and benefits (most hospitals require a separate signed consent). |
| Laboratory tests | Relevant results (e.g., INR / CBC). |
| Description of procedure | Brief description · sterile preparation · patient position · devices/implants (sutures, number, material) · anesthesia/sedation · location · drains · outcome. |
| Complications & EBL | Note complications (if any); if EBL is more than “minimal,” estimate the actual amount. |
| Disposition | How well the patient tolerated the procedure. |
| Specimens / findings | Findings, opening pressures, appearance of specimens, method of collection, time sent to laboratory. |
8/27/19 1300 — Chest tube placement.
Indications: moderate–large pleural effusion on CXR; patient with increasing SOB informed of risks/benefits and agrees (signed consent in chart).
Labs: PT/INR 12.2/1 · Hgb 16.2 · Hct 50 · PLT 352.
Patient placed in a left lateral decubitus position; area prepped and draped sterilely; 10 mL of 1% lidocaine injected into the intercostal space midaxillary line per protocol. A 20 F trocar chest tube inserted with immediate 1500 mL clear yellow drainage returned. Chest tube connected to Pleur-evac with 20 cm H₂O suction; no air leak. Specimens sent for cytology, pH, cell count, culture, Gram stain, LDH, protein, and glucose. No complications; patient tolerated the procedure well. CXR post-procedure pending.
Nancy Nurse, MSN, AGACNP-BC.
The discharge summary, in order
Fourteen components, from the moment of admission to the list of who gets copied. Hover each numbered segment for its component.
| # | Component | What it holds |
|---|---|---|
| 1 | Date of admission | Specify the date. |
| 2 | Date of discharge | Specify the date. |
| 3 | Admitting diagnosis | The main reason for the initial admission. |
| 4 | Discharge diagnosis | Primary diagnosis and any secondary diagnoses. |
| 5 | Attending / AGACNP / consultants | List names. |
| 6 | Procedures | Surgery and invasive diagnostic procedures (e.g., lumbar puncture, angiogram). |
| 7 | Brief history, pertinent PE & lab data | The most important points of the admission — brief H&P findings and admission labs. |
| 8 | Hospital course | Evaluation, treatment, and progress; treatments, medications, and the patient's response. |
| 9 | Discharge condition | Improved, deteriorated, or unchanged. |
| 10 | Disposition | Home, skilled nursing facility, or other hospital; who will assume care (if possible). |
| 11 | Discharge medications | Medications, dosages, scheduling, refill parameters; reconciliation of home medications. |
| 12 | Instructions & follow-up | Office appointments with follow-up dates; dietary instructions; activity requirements/restrictions. |
| 13 | Problem list | Active and past medical problems (if different from the discharge diagnosis). |
| 14 | Consultants & PCPs to copy | Consultants and primary care providers who should receive a copy of the discharge summary. |
Prescriptions
Two halves of the same rule: what a lawful prescription must contain, and the dangerous abbreviations that must never appear in one.
Patient & date
Patient's full name · date of birth · current date · designated pharmacy.
The Rx itself
- Drug name · strength · units · form
- Route — if ordering only a brand-name preparation, state or sign “no substitution”
Dispense
- Amount/number (e.g., mL/tabs) or a time period (e.g., a 1-month supply)
- Indicate whether — and how many — refills are authorized
Sig
Patient instructions — transcribed by a pharmacist onto the label of the dispensed medication.
Signature
Sign name and title; include the DEA number if the medication is a controlled substance.
Trailing zeros & naked decimals
- No trailing zeros — 1 mg, not 1.0 mg
- No “naked” decimal point — 0.5 mL, not .5 mL
Abbreviating drug names
Spell drug names out — do not abbreviate them.
U and IU
- No U — spell out “units”
- No IU — spell out “international units”
QD and QOD
- No QD — spell out “once a day” or “daily”
- No QOD — spell out “every other day”
The controlled-substance rules
Prescriptions for scheduled drugs must be written and signed on the day they are issued; the prescriber must have a DEA number (and, in some states, additional registrations), with the DEA number written or printed on the prescription.
- Written and signed on the day they are issued.
- The prescriber must hold a DEA number; some states require additional controlled-substance registrations.
- The DEA number must be written or printed on the prescription; some states also require the collaborating physician's DEA.
The required elements
- Patient's full name / DOB / current date / designated pharmacy
- Rx — drug name, strength, units, form, route (“no substitution” if brand-only)
- Dispense — amount/number or time period, plus refills
- Sig — patient instructions
- Signature — name, title, DEA if controlled
The dangerous abbreviations
- Trailing zeros (1 mg, not 1.0 mg)
- Naked decimals (0.5 mL, not .5 mL)
- Abbreviated drug names
- U (spell “units”) · IU (spell “international units”)
- QD (spell “daily”) · QOD (spell “every other day”)
If a prescription is conveyed electronically, the data in the electronic health record must be accurate:
- Patient: full name, date of birth, current date, designated pharmacy.
- Rx: drug name, strength, units, form, route — with “no substitution” if brand-only.
- Dispense: amount/number or time period, and authorized refills.
- Sig: patient instructions.
- Signature: name and title, with DEA number if a controlled substance.
Also note: computerized prescription generation is convenient, but inadvertent quantities can occur (e.g., 150 tablets entered instead of 15). The AGACNP can work with the software vendor to flag large numbers of tablets and prevent this error.
Rounds & Patient Presentation
Be brief and concise — the presentation of a patient during rounds should take less than 2–3 minutes per patient.
In under 2–3 minutes, cover these four items in order:
- Patient's name, age, gender, HPI, diagnosis, and any surgeries/procedures performed — and when.
- Pertinent data — the patient's current status; include abnormal laboratory results, tests, examinations, referrals, and so on.
- Diagnosis / differentials.
- Plan.
Who & what
Name, age, gender, HPI, diagnosis, surgeries/procedures and when they were performed.
Current status
Abnormal labs, tests, examinations, referrals — the data that matters now.
Diagnosis / differentials
State the diagnosis and the alternatives.
What happens next
The plan for the patient.
ICU Admission & Discharge Criteria
These are guidelines only — common sense and good clinical assessment always govern the decision. The reading lists example conditions by system for admission, and two broad reasons to move a patient out.
Cardiac conditions
- Acute MI with complications · cardiogenic shock
- Complex arrhythmias (VT, VF, SVT, atrial fibrillation)
- Acute CHF with respiratory failure or needing hemodynamic support
- Hypertensive emergencies · unstable angina (esp. with arrhythmias, hemodynamic instability, or persistent chest pain)
- Status post cardiac arrest · cardiac tamponade/constriction with hemodynamic instability
- Dissecting aortic aneurysm · complete heart block requiring a pacemaker
Pulmonary conditions
- Acute respiratory failure requiring ventilatory support
- Pulmonary emboli with hemodynamic instability
- Respiratory deterioration (or need for close observation/treatment) in a lower level of care
- Massive hemoptysis
- Respiratory failure with imminent need for intubation
Neurologic conditions
- Acute stroke with altered mental status · coma (metabolic, toxic, anoxic)
- Intracranial hemorrhage with potential for herniation · acute subarachnoid hemorrhage
- Meningitis with altered mental status or respiratory compromise
- CNS/neuromuscular disorders with deteriorating neurologic or pulmonary function
- Status epilepticus · brain-damaged or potentially brain-dead patients (organ donation)
- Vasospasm · severe head injuries · spinal cord injury
Drug ingestion & overdose
- Hemodynamically unstable drug ingestion
- Drug ingestion with significantly altered mental status and inadequate airway protection
- Seizures after drug ingestion
Gastrointestinal conditions
- Life-threatening GI bleeding — hypotension, angina, continued bleeding, or other comorbid conditions
- Fulminant hepatic failure
- Severe pancreatitis
- Esophageal perforation with or without mediastinitis
Endocrine & electrolyte conditions
- DKA complicated by hemodynamic instability, altered mental status, respiratory insufficiency, or severe acidosis
- Thyroid storm or myxedema coma with hemodynamic instability
- Hyperosmolar hyperglycemic nonketotic state · adrenal crises with hemodynamic instability
- Severe hypercalcemia with altered mental status · hypo/hypernatremia with seizures or altered mental status
- Hypo/hypermagnesemia with hemodynamic compromise or arrhythmias · hypo/hyperkalemia with arrhythmias or muscle weakness · hypophosphatemia with muscle weakness
Postoperative patients
Postoperative patients requiring hemodynamic monitoring, ventilatory support, or extensive nursing care.
Everything else
- Septic shock with hemodynamic instability
- Frequent hemodynamic monitoring requirements
- Conditions requiring frequent assessments, monitoring, or ICU-level nursing care
- Environmental injuries (lightning, near-drowning, hypothermia/hyperthermia, burns, inhalation injury)
- New/experimental therapies with potential for complications
ICU admission triggers, by system
Number of example conditions the reading lists under each system category. Hover a bar for the category.
Reasonable conditions, by system
Cardiac · pulmonary · neurologic · drug ingestion/overdose · gastrointestinal · endocrine · surgical · miscellaneous. The examples are grouped under these eight categories.
Keep in mind: these are only guidelines. Common sense and good clinical assessment always guide the decision.
Two reasons to move a patient out
- The patient's physiologic status has stabilized and ICU monitoring/care are no longer necessary.
- The patient's physiologic status has deteriorated and active interventions are no longer planned — so discharge to a lower level of care is appropriate.
The status of ICU patients should be continuously revised so those who no longer need ICU care are identified.
Electronic Medical Records
The EMR is a tool, not the patient. The chapter's guidelines cluster into three themes: patient focus and privacy, template and data hygiene, and safety and productivity.
The patient comes first
- Visually focus on the patient, not just the screen.
- Sign off the EHR when leaving the computer — to prevent privacy violations or inadvertent documentation by another provider.
- If using voice recognition, review the entries for accuracy.
Own what you sign
- EMRs include templates for H&P, SOAP, and procedure notes — edit them to only the elements pertinent to your practice.
- Data included in a template and signed by the practitioner indicates review and responsibility.
- Instead of deleting, comment that management of a problem will be done by a specific provider or service.
- Review, verify, and correct prefilled data; avoid copying and pasting past notes.
Use the machine's strengths
- Standard order sets for frequent diagnoses can improve outcomes and decrease complications — personalize each set and review/update periodically.
- Computerized order entry reduces errors, monitors interactions, and highlights labs; review and sign off flagged orders.
- Automatic date/time stamps enable auditing of cosigning, medications, and evaluation timing.
Providers who were studied felt their productivity decreased when EMRs were implemented. Strategies to maintain productivity include:
- Customizing order sets
- Customizing note templates
- Saving routine orders to favorite lists
- Providing access training
- Seeking information from other providers on ways to maximize use of the system
- Copy-and-paste of past notes — current, updated information is essential to demonstrate the patient's progress (or lack thereof).
- Prefilled data — review, verify, and correct; some systems have checkboxes indicating you have reviewed the information.
- Voice recognition — review entries for accuracy.
- Inadvertent prescription quantities — e.g., 150 tablets entered instead of 15; work with the vendor to flag large numbers of tablets.
- Signed template data — indicates you reviewed and are responsible for that parameter; if it does not apply, comment that management is by a specific provider or service.
Most EMRs report critical results to the clinician as they sign onto the system — a useful setting that lets you prioritize which patients to see. Spend an appropriate amount of time evaluating critical alerts: the system records the time spent viewing alerts.
Ensure the system is set to let you access patient lists for providers you are covering, and develop a backup method of communicating patient lists in case of system maintenance, failure, access errors, or list errors. A method to sign patients out to covering providers gives you an opportunity to provide more detail than an EMR.
What to lock in
Anchor each document to its structure, and each rule to its trigger. These are the high-yield contrasts to carry forward from Week 1.
The HPI mnemonics
OLD CARTS (Onset, Location, Duration, Characteristics, Aggravating, Relieving, Treatment, Severity 1–10) and PQRST + 3 As (Provocative, Quality, Radiation, Severity, Timing, Alleviating, Associated, Aggravating).
The admission-orders mnemonic
A.D.C. VAAN DISSL — Admit/attending, Diagnosis, Condition, Vital signs, Activity, Allergies, Nursing, Diet, Intake/output, Specific meds, Symptomatic meds, Labs — plus consults.
The notify parameters
Call the provider for SBP > 170 mmHg, O₂ saturation < 90%, urine output < 30 mL/hr, fever criteria, or a change in the neurological exam.
The SOAP note
Subjective → Objective → Assessment → Plan, framed by date/time/service. Mark abnormal labs up or down from prior.
The procedure note
Date/time → procedure → indications → consent → labs → description → complications & EBL → disposition → specimens. Document every invasive procedure.
The discharge summary
Fourteen components, admission date through the copy list. Don't drop the reconciliation, the instructions, or the problem list.
Dangerous abbreviations
No trailing zeros, no naked decimals, no abbreviated drug names, no U/IU, no QD/QOD. Spell out units, international units, daily, every other day.
ICU discharge
Move a patient out when they have stabilized and no longer need ICU care — or deteriorated with no further active interventions planned.
Rounds & the EMR
Present each patient in under 2–3 minutes. On the EMR, sign off when you leave, verify prefilled data, and never copy-paste past notes.
Write the admission, order the care, document the stay, and hand off the discharge — completely and in the patient's own frame.
Rapid-fire review
Answer out loud first, then reveal. Twelve questions covering the whole chapter.
You pull information from the chart for a consult H&P. What must you always do before using it?
Confirm the information with the patient — or note that it came from another source (caregiver or family member) and is unverifiable. Also include your own physical findings, impressions, and differentials, even if they differ from the chart.
Decode the “OLD CARTS” mnemonic.
Onset · Location · Duration · Characteristics · Aggravating factors · Relieving factors · Treatment · Severity (preferably on a 1–10 scale).
Decode “PQRST + 3 As.”
Provocative factors · Quality · Radiation · Severity · Timing · Alleviating factors · Associated factors · Aggravating factors.
What does the admission-orders mnemonic “A.D.C. VAAN DISSL” stand for?
Admit/attending · Diagnosis · Condition · Vital signs · Activity · Allergies · Nursing procedures · Diet · Intake/output · Specific medications · Symptomatic medications · Laboratory/diagnostic procedures — plus consults.
Name the three numeric parameters (from the admission orders) that should trigger a call to the MD or AGACNP.
Systolic blood pressure > 170 mmHg · oxygen saturation < 90% · urine output < 30 mL/hr. (The reading also lists fever criteria and a change in the neurological exam.)
What are the five parts of a SOAP progress note, and what belongs in each?
Date/time/service · Subjective (how the patient feels, complaints in quotations, past 24 hours) · Objective (appearance, vitals, I/O, exam changes, labs) · Assessment/diagnosis (per problem, status active/resolved) · Plan (order changes, new labs/tests/meds, disposition). Mark abnormal labs as up or down from prior.
How long should an oral patient presentation during rounds take, and what four items does it cover?
Less than 2–3 minutes per patient. Cover (1) name, age, gender, HPI, diagnosis, surgeries/procedures and when; (2) pertinent data — current status, abnormal labs/tests/exams/referrals; (3) diagnosis/differentials; (4) plan.
List the components a procedure note must document.
Date/time · procedure · indications · patient consent · laboratory tests · description of procedure (sterile prep, position, devices/implants, anesthesia, location, drains, outcome) · complications & estimated blood loss · disposition · specimens/findings. If EBL is more than “minimal,” estimate the actual amount.
Name the fourteen components of a discharge summary.
Date of admission · date of discharge · admitting diagnosis · discharge diagnosis · attending/AGACNP/consultants · procedures · brief history + pertinent PE + lab data · hospital course · discharge condition · disposition · discharge medications · instructions & follow-up · problem list · consultants/PCPs to copy.
What are the rules for prescribing scheduled (controlled) drugs?
They must be written and signed on the day they are issued. The prescriber must have a DEA number (some states require additional controlled-substance registrations), and the DEA number must be written or printed on the prescription — some states also require the collaborating physician's DEA.
Name the “dangerous abbreviations” to avoid in prescriptions and orders.
No trailing zeros (1 mg, not 1.0 mg) · no naked decimal (0.5 mL, not .5 mL) · no abbreviated drug names · no U (spell “units”) · no IU (spell “international units”) · no QD (spell “once a day”/“daily”) · no QOD (spell “every other day”).
What are the two general guidelines for discharging a patient from the ICU?
(1) The patient's physiologic status has stabilized and ICU monitoring/care are no longer necessary. (2) The physiologic status has deteriorated and active interventions are no longer planned, so discharge to a lower level of care is appropriate.
Sources
Every statement above comes from the assigned Week 1 reading — Chapter 85 of Practice Considerations for Adult-Gerontology Acute Care Nurse Practitioners.
Chapter
Kuric, J. (2021). Hospital admission considerations. In Practice considerations for adult-gerontology acute care nurse practitioners (Chapter 85).
Selected sources cited in the reading
Balestra, M. L. (2017). Electronic health records: Patient care and ethical and legal implications for nurse practitioners. The Journal for Nurse Practitioners, 13(2), 105–111.
Buppert, C. (2011). 10 habits to adopt to avoid prescribing errors. Journal for Nurse Practitioners, 7(7), 600–601.
El-Kareh, R., Gandhi, T. K., Pogue, E. G., et al. (2009). Trends in primary care clinician perceptions of a new electronic health record. Journal of General Internal Medicine, 24(4), 464–468.
Klein, T., & Kaplan, L. (2010). Prescribing competencies for advanced practice registered nurses. The Journal for Nurse Practitioners, 6(2), 115–122.
McMullen, P. C., Howie, W. O., Phillipson, N., Bryant, V. C., Setlow, P. D., Calhoun, M., & Green, Z. D. (2014). Electronic medical records and electronic health records: Overview for nurse practitioners. The Journal for Nurse Practitioners, 10(9), 660–665.