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4724400-44767500COVID-19?CLINICAL GUIDELINES?????SUBJECT: REDUCED NURSING DOCUMENTATION DURING A CRISISSCOPE: Sinai Hospital of Baltimore and Northwest Hospital adopt the following guidelines for documenting clinical services provided during the COVID-19 pandemic.??????APPROVED BY:?LBH Clinical Guidelines Council?????APPROVAL DATE: 12/16/2020;?LAST REVIEW DATE:?Applicable to patients classified as Emergency Room and Critical Care Patients regardless of their location in the facilityEmergency Department PatientsInitial Assessment: Per department routine. Focused Assessment: Documented based on changes in patient condition. Critical Care Patients (Inpatient)Assessment – Critical Care Patients Initial Assessment: Completed and documented within the first four (4) hours of the beginning of the shift.Focused Assessment: Completed and documented by exception with a four (4) hour frequency Any change in patient condition requires documentation within two (2) hours of the changeInterventions as ordered by the Medical Provider (Physician, Nurse Practitioner and/or Physician Assistant) or defined as standard of care are followed as prescribed.Note: Disruptions in supply chain associated with long-term crises may require alterations (e.g., if medications are not packaged with bar codes, barcode administration cannot be utilized, and five (5) Rights are verified by staff without technology assistance) in documentation standards. CROSS REFERENCES:Patient Care Services: Admission of the Patient, Nursing AssessmentBlood and/or Blood Component Transfusion High Risk/High Alert Medications Intravenous MedicationMedication Use Process – Ordering, Administation, and Documentation Protocol: Skin Impairement: Alterations, Prevention and Treatment ................
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