What’s New at Rady Children’s ED

  • Computerized tracking.
  • ChartMaxx
  • Patient information sheet – read and sign it!
  • Dealing with Violence in the Workplace.  This is required training.
  • HIPAA Privacy Training requirements http://health.ucsd.edu/compliance/hipaa.shtml
  • JCAHO/Department of Health – may visit without warning:
    – No food or drinks in patient-care areas.
    – Keep patient information confidential: cover charts, close computer screens.

Frequently encountered issues with the dictation system:

  • Please remember to dictate your charts before leaving.
  • Follow the template (appendix A).  Don’t forget:
  • Time initially seen:
    • ROS, FH, SH (Refer to patient info sheet. State that you reviewed it.)
    • PE should include at least vs/ general appearance.  HEENT/chest/heart/abd/ext/skin/neuro. (Don’t forget, especially for head trauma patients!)
    • Medical course/decision making: Include thought process, related diagnoses, consults, discussion with family/PMD.
      Procedure notes
      CC to PMD