View source for IBID Admission

{{topic|IBID}}


IBID Admission fields record the Admission of the patient to the burns service and should be completed if the patient is formally admitted into a bed within the burn ward. This will often be the date of the first assessment or admission, but not invariably so.


[[file:Admission.jpg]]

=IBID Admission Fields=

''Admission Date''- Once a Patient is formally admitted to the burns service the date the patient was first admitted will need to be entered in this field. This date will often be the date of the first assessment, but not invariably so if the patient has had other episodes or treatment. This is a KPI required field

''Admission Time'' - An accurate time needs to be entered to allow patent care monitoring and calculations to be made. This is a KPI required field.

''Injury to Admin Delay'' - An automatically calculated field that displays the time delay from the initial injury to admission. 

''Admitting Nurse'' - Choose the name of the admitting nurse from the drop down list. This list is generated from Staff entered by the Administrator in System Administration.

=First Seen and Assessed By=

''Admission Ward'' - Free type in the name of the ward the patent is admitted to.

''Seen BY Who'' - Choose from a drop down list the member of staff responsible for initial assessment of injury severity. This list is generated from Staff Entered in to Administration by System Administrator. If the member of staff isn't included in the drop down list, the staff members name can be free typed in to the field.

''Date Seen'' - Free type or choose correct date from drop down calendar.

''Time Seen'' - What time the patent was seen.

''Seen By Grade'' - Automatically filled in field once the "Seen by Who" field is filled in from the drop down list, and the information has been added by Administration. If the user isn't included in the "Seen by who" staff list the grade can be chosen from the drop down list. 

''Seen By Speciality'' - Choose the speciality of the assessor from drop down list.

''Admitting Speciality'' - Choose the speciality of the person responsible for admitting the patient from the drop down list.

''Admitting Consultant'' - Choose from a drop down list the member of staff responsible for admitting the patient. This list is generated from Staff Entered in to Administration by System Administrator. If the member of staff isn't included in the drop down list, the staff members name can be free typed in to the field.


=GCS=

''Eye Opening'' - Choose from the drop down list the best GCS assessment score for patients eye opening.

''Motor Response'' - Choose from the drop down list the best GCS assessment score for the patients motor response.

''Verbal Response'' - Choose from the drop down list the patients GCS assessment score for Verbal response.

''Sedated Vent'' - Tick box to establish if the patient was sedated or mechanically ventilated, at the time of GCS assessment.

''GC Score'' - Automatically generated field that shows the total GC score of the patient upon admission.

=Admission Comments Fields=

''Admission comments'' - Free text field for additional information and comments regarding the patients admission.

''Complications Attributable to Transfer'' -  An additional free text filed for information regarding any complications attributable to the transfer of the patient. 

=Physiology=

''Core Temperature'' - Enter the patient's core temperature (Celsius)when first seen.

''PR'' - Enter the patients pulse rate (beats per minute) when first seen.

''RR'' - Enter the patients respiratory rate (breaths per minute) when first seen.

''Systolic BP'' - Enter the patients systolic blood pressure upon admission. Systolic blood pressure represents the minimum pressure in the arteries and will be the lower of the two blood pressure numbers. 

''Diastolic PB'' - Enter the diastolic blood pressure upon admission. Diastolic blood pressure represents the maximum pressure with in the arteries and will be the higher of the two blood pressure numbers. 

''Capillary Refill'' - Enter the patients capillary refill rate at the time of admission. Normal capillary refill time is less that 2 seconds.

''Pulse Oximetry'' - If pulse oximetry was performed please tick box.

''Pulse Oximetry'' - Enter the pulse oximetry percentage.


=Does the Patient Exhibit These Symptoms =

These Questions form part of the Apache 11 trauma scoring system and are made up of tick box field's. they give an indication of the patients medical condition upon admission. Tick the relevant box if the patent shows signs of any of these conditions.

[[File:Tickbox exibit symptoms.jpg]]

''A tick in the field'' - Denotes a positive, yes, or an acknowledgement of the condition.

''A field left blank''  -Denotes a negative, no, or an acknowledgement that the condition is not present.

''A grey tick in the box'' - Denotes that the information required is not known.

''Uncheck all button'' - Click this button to clear all of the symptoms fields to show a negative or no acknowledgement of the conditions shown.

=First Seen by Consultant=

This should be the date on which the patient was first seen by the relevant Consultant that forms part of the burn care multidisciplinary team.

''Date seen''- Choose from drop down list or free type date in to date field.

''Time Seen'' - Free type time or scroll using up and down arrows to correct time.

''Consultant Name'' - Enter the name of the consultant from the drop down list.

''Consultant Code'' - this filed is an Automatically filled in field once the consultants name is entered. The Consultant code is derived from the General Medical Council reference number for General Medical Practitioners and is normally prefixed with a C.

In some cases the patient will have sustained an airway injury, in this instance the patient record type chosen will be "Acute Major Injury Admission (resus &/or significan inhilation)" for further information regarding the Airway Injury field, please follow the link to [[IBID Airway Injury]].

= Editor Types =

{{Editor Types}}

[[category:User Help]]
[[category:AquilaCRS]]
[[category:IBID]]