Seol Suggested VA Inpatient Checklist (Printable)

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posted 2023-12-28, updated 2024-06-13
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Checklist

History & Physical (H&P):
[radio name="h_and_p_status" value="Completed|Pending|Needs Review|Updated"]

Admission Orders:
[radio name="admission_orders_status" value="Completed|Pending|Needs Review|Updated"]

Medication Reconciliation (Med Rec):
[radio name="med_rec_status" value="Completed|Pending|Needs Review|Updated"]

AM Labs:
[radio name="am_labs_status" value="Ordered|Results Reviewed|Pending|Follow-up Required"]

Work Up (Additional Tests/Procedures):
[radio name="work_up_status" value="Ordered|Completed|Pending|Needs Review"]

Physical Therapy/Occupational Therapy (PT/OT):
[radio name="pt_ot_status" value="Evaluated|Scheduled|Pending|In Progress"]

Fluids, Electrolytes, and Nutrition (FEN) Orders:

IV Fluids:
[radio name="iv_fluids" value="None|Normal Saline|Half Normal Saline|Lactated Ringer's|Dextrose Solution|Custom"]
Specify if custom: [text name="custom_iv_fluid"]

Electrolyte Repletion:
[radio name="electrolyte_repletion" value="None|Potassium Chloride|Magnesium Sulfate|Calcium Gluconate|Sodium Chloride|Multivitamin|Thiamine|Folic Acid|Custom"]
Specify if custom: [text name="custom_electrolyte"]

Nutrition:
[radio name="nutrition" value="Regular Diet|Diabetic Diet|Cardiac Diet|Renal Diet|NPO|TPN|Enteral Feeding|Custom"]
Specify if custom: [text name="custom_nutrition"]

Dietary Supplements:
[radio name="dietary_supplements" value="None|Multivitamin|Calcium|Iron|Vitamin D|Omega-3 Fatty Acids|Other"]
Specify if other: [text name="other_supplements"]

Fluid Restriction:
[radio name="fluid_restriction" value="No Restriction|Restrict to 1.5L/day|Restrict to 2L/day|Custom Restriction"]
Specify if custom restriction: [text name="custom_fluid_restriction"]

--

Gastrointestinal (GI) Management:
[radio name="gi_management_status" value="Managed|Pending Review|Adjustments Needed|Stable"]

Prophylaxis (PPx):
[radio name="ppx_status" value="Infection PPx|Ulcer PPx|Other"]

Deep Vein Thrombosis Prophylaxis (DVT PPx):
[radio name="dvt_ppx_status" value="Ordered|Not Indicated|Contraindicated|Pending"]

Diet:
[radio name="diet_status" value="Regular|Low Sodium|Diabetic|Renal|NPO|Other"]

Intravenous Fluids (IVF):
[radio name="ivf_status" value="Ordered|Adjusted|Discontinued|Stable"]

Handoff Updated:
[radio name="handoff_updated_status" value="Yes|No|Pending"]

Sign Out:
[radio name="sign_out_status" value="Completed|Pending|Needs Review"]

Consults Placed:
[radio name="consults_placed_status" value="Completed|Pending|No Consults Needed"]

Dispo Planning (Disposition Planning):
[radio name="dispo_planning_status" value="Completed|Pending|In Progress|Not Started"]

PCP Contact (Primary Care Physician Contact):
[radio name="pcp_contact_status" value="Completed|Pending|Scheduled|Not Applicable"]

Follow Up Appointment:
[radio name="follow_up_appointment_status" value="Scheduled|To Be Scheduled|Not Needed|Not Applicable"]

Transportation Arrangements:
[radio name="transportation_status" value="Arranged|To Be Arranged|Not Needed|Not Applicable"]

Medication Reconciliation/Pharmacy Recommendations:
[radio name="med_rec_pharmacy_recs_status" value="Completed|Pending|In Progress|Not Started"]

Physical Therapy/Occupational Therapy Recommendations:
[radio name="pt_ot_recs_status" value="Provided|Pending|Not Needed|Not Applicable"]

Walk Patient (Ambulation Plans):
[radio name="walk_patient_status" value="Completed|Pending|In Progress|Not Applicable"]

Consult Recommendations:
[radio name="consult_recs_status" value="Received|Pending|Not Needed|Not Applicable"]

Home Health Orders:
[radio name="home_health_orders_status" value="Ordered|Pending|Not Needed|Not Applicable"]

Discharge Summary:
[radio name="discharge_summary_status" value="Completed|Pending|In Progress|Not Started"]

IV Fluids: [radio name="patient1_iv_fluids" value="None|Normal Saline|Half Normal Saline|Lactated Ringer's|Dextrose Solution|Custom"]

Electrolytes: [radio name="patient1_electrolytes" value="None|Potassium|Magnesium|Calcium|Sodium|Custom"]

Nutrition: [radio name="patient1_nutrition" value="Regular Diet|Diabetic Diet|Cardiac Diet|Renal Diet|NPO|TPN|Enteral Feeding|Custom"]

Teaching Points


Patient 1:
IV Fluids: [radio name="patient1_iv_fluids" value="None|Normal Saline|Half Normal Saline|Lactated Ringer's|Dextrose Solution|Custom"]
Electrolytes: [radio name="patient1_electrolytes" value="None|Potassium|Magnesium|Calcium|Sodium|Custom"]
Nutrition: [radio name="patient1_nutrition" value="Regular Diet|Diabetic Diet|Cardiac Diet|Renal Diet|NPO|TPN|Enteral Feeding|Custom"]
Teaching Points: [textarea name="patient1_teaching_points"]

Patient 2:
IV Fluids: [radio name="patient2_iv_fluids" value="None|Normal Saline|Half Normal Saline|Lactated Ringer's|Dextrose Solution|Custom"]
Electrolytes: [radio name="patient2_electrolytes" value="None|Potassium|Magnesium|Calcium|Sodium|Custom"]
Nutrition: [radio name="patient2_nutrition" value="Regular Diet|Diabetic Diet|Cardiac Diet|Renal Diet|NPO|TPN|Enteral Feeding|Custom"]
Teaching Points: [textarea name="patient2_teaching_points"]

Patient 3:
IV Fluids: [radio name="patient3_iv_fluids" value="None|Normal Saline|Half Normal Saline|Lactated Ringer's|Dextrose Solution|Custom"]
Electrolytes: [radio name="patient3_electrolytes" value="None|Potassium|Magnesium|Calcium|Sodium|Custom"]
Nutrition: [radio name="patient3_nutrition" value="Regular Diet|Diabetic Diet|Cardiac Diet|Renal Diet|NPO|TPN|Enteral Feeding|Custom"]
Teaching Points: [textarea name="patient3_teaching_points"]

Patient 4:
IV Fluids: [radio name="patient3_iv_fluids" value="None|Normal Saline|Half Normal Saline|Lactated Ringer's|Dextrose Solution|Custom"]
Electrolytes: [radio name="patient3_electrolytes" value="None|Potassium|Magnesium|Calcium|Sodium|Custom"]
Nutrition: [radio name="patient3_nutrition" value="Regular Diet|Diabetic Diet|Cardiac Diet|Renal Diet|NPO|TPN|Enteral Feeding|Custom"]
Teaching Points: [textarea name="patient3_teaching_points"]

Patient 5:
IV Fluids: [radio name="patient3_iv_fluids" value="None|Normal Saline|Half Normal Saline|Lactated Ringer's|Dextrose Solution|Custom"]
Electrolytes: [radio name="patient3_electrolytes" value="None|Potassium|Magnesium|Calcium|Sodium|Custom"]
Nutrition: [radio name="patient3_nutrition" value="Regular Diet|Diabetic Diet|Cardiac Diet|Renal Diet|NPO|TPN|Enteral Feeding|Custom"]
Teaching Points: [textarea name="patient3_teaching_points"]

Patient 6:
IV Fluids: [radio name="patient3_iv_fluids" value="None|Normal Saline|Half Normal Saline|Lactated Ringer's|Dextrose Solution|Custom"]
Electrolytes: [radio name="patient3_electrolytes" value="None|Potassium|Magnesium|Calcium|Sodium|Custom"]
Nutrition: [radio name="patient3_nutrition" value="Regular Diet|Diabetic Diet|Cardiac Diet|Renal Diet|NPO|TPN|Enteral Feeding|Custom"]
Teaching Points: [textarea name="patient3_teaching_points"]

Patient 7:
IV Fluids: [radio name="patient3_iv_fluids" value="None|Normal Saline|Half Normal Saline|Lactated Ringer's|Dextrose Solution|Custom"]
Electrolytes: [radio name="patient3_electrolytes" value="None|Potassium|Magnesium|Calcium|Sodium|Custom"]
Nutrition: [radio name="patient3_nutrition" value="Regular Diet|Diabetic Diet|Cardiac Diet|Renal Diet|NPO|TPN|Enteral Feeding|Custom"]
Teaching Points: [textarea name="patient3_teaching_points"]

Patient 8:
IV Fluids: [radio name="patient3_iv_fluids" value="None|Normal Saline|Half Normal Saline|Lactated Ringer's|Dextrose Solution|Custom"]
Electrolytes: [radio name="patient3_electrolytes" value="None|Potassium|Magnesium|Calcium|Sodium|Custom"]
Nutrition: [radio name="patient3_nutrition" value="Regular Diet|Diabetic Diet|Cardiac Diet|Renal Diet|NPO|TPN|Enteral Feeding|Custom"]
Teaching Points: [textarea name="patient3_teaching_points"]

Patient 9:
IV Fluids: [radio name="patient3_iv_fluids" value="None|Normal Saline|Half Normal Saline|Lactated Ringer's|Dextrose Solution|Custom"]
Electrolytes: [radio name="patient3_electrolytes" value="None|Potassium|Magnesium|Calcium|Sodium|Custom"]
Nutrition: [radio name="patient3_nutrition" value="Regular Diet|Diabetic Diet|Cardiac Diet|Renal Diet|NPO|TPN|Enteral Feeding|Custom"]
Teaching Points: [textarea name="patient3_teaching_points"]

Patient 10:
IV Fluids: [radio name="patient10_iv_fluids" value="None|Normal Saline|Half Normal Saline|Lactated Ringer's|Dextrose Solution|Custom"]
Electrolytes: [radio name="patient10_electrolytes" value="None|Potassium|Magnesium|Calcium|Sodium|Custom"]
Nutrition: [radio name="patient10_nutrition" value="Regular Diet|Diabetic Diet|Cardiac Diet|Renal Diet|NPO|TPN|Enteral Feeding|Custom"]
Teaching Points: [textarea name="patient10_teaching_points"]

Checklist

History & Physical (H&P):


Admission Orders:


Medication Reconciliation (Med Rec):


AM Labs:


Work Up (Additional Tests/Procedures):


Physical Therapy/Occupational Therapy (PT/OT):


Fluids, Electrolytes, and Nutrition (FEN) Orders:

IV Fluids:

Specify if custom:

Electrolyte Repletion:

Specify if custom:

Nutrition:

Specify if custom:

Dietary Supplements:

Specify if other:

Fluid Restriction:

Specify if custom restriction:

--

Gastrointestinal (GI) Management:


Prophylaxis (PPx):


Deep Vein Thrombosis Prophylaxis (DVT PPx):


Diet:


Intravenous Fluids (IVF):


Handoff Updated:


Sign Out:


Consults Placed:


Dispo Planning (Disposition Planning):


PCP Contact (Primary Care Physician Contact):


Follow Up Appointment:


Transportation Arrangements:


Medication Reconciliation/Pharmacy Recommendations:


Physical Therapy/Occupational Therapy Recommendations:


Walk Patient (Ambulation Plans):


Consult Recommendations:


Home Health Orders:


Discharge Summary:


IV Fluids:

Electrolytes:

Nutrition:

Teaching Points


Patient 1:
IV Fluids:
Electrolytes:
Nutrition:
Teaching Points:


Patient 2:
IV Fluids:
Electrolytes:
Nutrition:
Teaching Points:


Patient 3:
IV Fluids:
Electrolytes:
Nutrition:
Teaching Points:


Patient 4:
IV Fluids:
Electrolytes:
Nutrition:
Teaching Points:


Patient 5:
IV Fluids:
Electrolytes:
Nutrition:
Teaching Points:


Patient 6:
IV Fluids:
Electrolytes:
Nutrition:
Teaching Points:


Patient 7:
IV Fluids:
Electrolytes:
Nutrition:
Teaching Points:


Patient 8:
IV Fluids:
Electrolytes:
Nutrition:
Teaching Points:


Patient 9:
IV Fluids:
Electrolytes:
Nutrition:
Teaching Points:


Patient 10:
IV Fluids:
Electrolytes:
Nutrition:
Teaching Points:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.81, 77 form elements, 188 boilerplate words, 5 text boxes, 10 text areas, 62 radio buttons, 77 total clicks
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