Work-Flow
Step 1: patient is identified as appropriate obs candidate (eg. 55 year old with hx of smoking and 15 minutes of left chest pain, normal ecg). The basic ED workup is done by the a or b team as it would usually proceed. The resident/pa/attending primarily caring for the patient will answer the questions on the “observation pathway” on the dispo tab, signout the patient to the NP and have them moved to the obs unit.
Step 2: The attending primarily caring for the patient will then go to the OBS tab, click on the “observation order begin” to write the order which starts obs and write a note (now this note is called risk stratification and obs plan) which needs to include: 1-2 lines about risk stratification of the patient and 1-2 lines about the observation plan. For billing, it is very important that the word RISK be in the risk stratification statement.
examples could include:
55M with TOB hx and normal ecg is low risk for acs. plan for observation with serial enzymes, monitoring, ecg’s and cardiology evaluation.
43F with symptoms concerning for acs, pt meets low risk criteria. plan for observation including monitoring, repeat ecg’s, cardiac enzymes and provocative testing.
The primary attending will keep that patient until the end of their shift.
Step 3: the NP’s will continue to manage their workflow as they have been, with their notes indicating the intensity of services appropriate to obs status (though we would also like to move all obs patients into the obs unit).
Step 4: The primary attending will sign out the patient to their relief, just as they would any other patient under their care. The receiving attending will be responsible to cover the NP’s who will be primarily coordinating the patent’s care. Every attending that the patient “goes through” needs to write a brief progress note on the chart. The progress note can be brief – 1 line. (eg. patient comfortable, no further episodes of CP, repeat ecg normal, pending cardiology evaluation in am). The NP’s should handle the rest of the work.
Step 5: at 10am, the a/b attendings will sign out the obs patients to the oncoming FT attending (the FT attending should go and seek out this signout). At this point, the FT attending should go and see the patients and should write a brief progress note (eg. patient had no episodes of chest pain overnight, serial enzymes negative, pending stress echo.).
Step 6: When the patient is ready to be discharged, it is the FT attending who is responsible to review the case and really needs to be the one to make sure that the patient doesn’t have other occult pathology and is safe for discharge. That attending will also have to write a 1-2 line discharge summary and plan on the link called “discharge summary and plan.” Then the FT attending will have to click on the obs end line and put the order to end observation in teletracking. The NP’s should handle the rest of the work. If the patient is admitted, this attending will have to write 1 line in the chart discussing the reason for admission (eg. patient with complex issues including syncope and chest pain, requiring inpatient evaluation and testing AS RECOMMENDED BY CARDIOLOGY). The last part is to hopefully prevent medicine from simply discharging these patients directly.
examples of documentation could include:
55M presented with chest pain, low risk for acs. cardiology recommended stress echo which was negative and plan for follow up in mpc clinic in 2 weeks for further eval.
40M presented with epigastric pain. low risk for acs. cardiology evaluated the patient and felt that symptoms were related to a GI source and the patient was safe for discharge. I re-evaluated the patient who has remained pain free with normal labs, cxr, cardiac enzymes and ecg’s. Plan to start ppi and have patient follow up with diagnostic clinic in 1 week.
