All patients admitted to MGH must have an order that designates their admission status as inpatient, observation, or routine post-procedure recovery (RPPR).
Exact terminology is required by the US Department of Health and Human Services Office of the Inspector General (OIG). Text entered via the General Care > Other order is not acceptable to fulfill the requirement.
MDs, NPs, PAs, and CNMs writing pre-admission, admission, or post-op orders are prompted for the admission status on signing.
A reminder to consult the case manager displays at the top of the Sign tab if the patient has been in-house for 24 hours or longer with an admission status of observation or RPPR.
If the patient's admission status must be changed, you must write an order to sign.
See also: Presentation on Patient Admission Status
If you haven't already:
Write orders for the patient, then click Close to return to the Orders For This Session scratch pad. See Writing Orders. If you are changing the admission status, write a change status order. There are two (2) options:
Select the order from the Change Status set in the Admission Orders templates. See Sets and Templates > Ordering a change to the patient's admission status (inpatient only).
Write a General Care > Other order, typing "Change status" for the description.
Click Sign (ALT+S).
Click the Document Admission Status tab.
If you are editing the patient's status, the current status and reasons are displayed. Click Change (ALT+C).
For the initial set of orders, if possible, a status is recommended based on the patient's location.
Click to select a status option: inpatient, observation, or routine post-procedure recovery (RPPR).
Click to select a reason for admission. If none of the options on the list is applicable, click to select a different status, or use Help me decide.
To select an indication first, which automatically updates the admission status appropriately:
Click the Help me decide tab.
Click to select a reason for admission. The appropriate status option is selected automatically.
If the status is not correct, click to select another. The reason you selected is cleared.
Click to select a reason from the list below the status.
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
To complete the entry, click OK (ALT+O).
See also: Signing Orders