December 10, 2013—Rationale for Admission
All patients admitted to MGH must have an order that designates their admission status as inpatient, observation, or routine post-procedure recovery (RPPR). For patients admitted as inpatients, the field to describe the rationale for admission is displayed automatically. Depending on the patient's insurance, this information may be required; if so, the field is flagged as such.
Type to describe the clinical judgements that determined the medical necessity for admitting this patient for inpatient care. Consider all of the following:
For a patient admitted for an inpatient surgical procedure, type this form with the applicable names: "Mr./Ms. Patient Last Name is being admitted as an inpatient for name of procedure."
Patient history and the presence of complicating symptoms or conditions
Severity of the patient's condition
Risk of adverse events if the patient is not admitted
Any aspects of the patient's condition that are not readily apparent but do help justify the admission
Key Features:
MDs, NPs, PAs, and CNMs writing pre-admission, admission, or post-op orders are prompted for the admission status on signing
If the status is set to Inpatient, the field for Rationale for Admission is presented automatically
This information is optional at present
For more, see the What's New from February 19, 2013 on Documenting Patient Status on Admission
Instructions: Documenting Patient Admission Status
See also: