Significant Event Notes

Significant event notes template¶

What is a 'significant event'¶

Definition for our group :¶

'Includes rapid response, code blue, acute worsening of clinical condition, need for bedside evaluation or urgent imaging, labs, consults or therapeutics'

Simplified definition :¶

'If you need to go to the bedside to evaluate a patient, write a note'

Definition from UNC Systems Hospitalist Significant Event Alert workgroup

Rapid response
Unexpected deterioration
New need for significantly more oxygen than before
Change in condition that required hands-on care of the patient by the physician/APP at the bedside
0 Transfer to the ICU or higher level of care
New event
0 Perhaps new CVA or Ml, depending on whether your entity uses navigators
Unexpected results (e.g., new PE on scan)
New diagnosis of sepsis,need for repeat sepsis exam
Change in code status or goals of care if not already clearly documented in an Advance Care Planning (AcP) note
Death, even if expected
At risk to clinician
Agitated family, violent patient
Any notification that is important and time-sensitive

Why document (ideally in a standardized fashion) when significant events occur?¶

 Improves communication to ALL members of the healthcare team ( not just to our group )¶

 Ensures information is available for duration of hospitalization
 Sticky notes get edited/updated
 Potential to reduce 'chart wars'
 Improves culture of safety/teamwork
 Documentation is a clear signal concern(s) were taken seriously
 Potential for increased critical care billing
 important for Medicolegal purposes
 'If it wasn't documented, it didn't happen…..

.SIGNIFICANTEVENTNOTE¶

Template includes¶

1) Reason for evaluation
2) Brief assessment & plan
3) Attestation for critical care billing ( if applicable )

Use of significant event note type template creates a significant event alert icon (red diamond) which can be viewed from your patient list Example of a completed significant event note

Significant Event* Note¶

*Includes a rapid response, code blue, acute worsening of clinical condition, need for bedside evaluationof the patient, or need for urgent imaging, labs, consults, or therapeutics

Called to bedside at 10:35 PM for tachycardia.¶

Upon my arrival, patient remained comfortable appearing, but was persistently tachycardic to 149 despite 5 L IV fluid resuscitation in the setting of his DKA presentation. He had been assessed intervally with each IV fluid bolus to the aftermoon, and he now felt like his volume status was more 90s low 100s over 70s. Per his spouse earlier, this was typical for him. He developed lower blood sugars early in the aftermoon in the 50s and 60s, and his insulin drip was stopped.

Pertinent exam findings include moist mucous membranes, tachycardia to 150, moving all extremity equally, at baseline mental status. No increased respiratory effort.

Vitals -¶

Vitals:	05/10/22 2310
BP:	98/73
Pulse.	129
Resp:	14
Temp: Sp02:	9696

Assessment/Plan:¶

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I initially provided 6 mg of adenosine with no change, 12 mg of adenosine with brief slowing of the heart rate to 140 without a clear cause. Next we trialed metoprolol 5 mg IV x3. Initially this decrease his rate to 140 then 120s, although the third dose provided no additional benefit. His blood pressures remained stable during this time. At this point, my suspicion for pulmonary embolism is increased; nuclear medicine study was ordered earlier today but unable to be performed. Given higher suspicion (with elevated D-dimer), would ensure patient is stabilized in ICU setting and pursue available study depending on hospital. Current plan to transfer to Hillsboro.

Treatment and additional workup per below:¶

-Continue dextrose containing maintenance IV fluids and insulin drip ovemight
remains in 120s and blood pressure stable, can continue to observe overnight.

-Plan discussed with Primary RN, Patient and cardiologist; handoff provided to accepting hospitalist at Hillsboro via epic chat

-Continue current level of care (CCU at HBR)

The patient is critically ill with the above illnesses as this illness acutely impairs one or more vital organ systems such as that there is a high probability manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or prevent further life threatening deterioration of the patient's condition. I personally spent 50 minutes, excluding procedures, in critical care time examining the patient, evaluating the hemodynamic, laboratory, and radiographic data, developing a comprehensive management plan, and serially assessing the patient's response to our critical care interventions.

Minimum 30 min¶

If you use the Critical Care attestation…. Don't forget to Bill for critical care services (99291)!¶

The patient is critically ill with the above illnesses as this illness acutely impairs one or more vital organ systems such as that there is a high probability of imminent or life threatening detenioration in the patient's condition without proper intervention. I utilized high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or prevent further life threatening deterioration of the patient's condition. I personally spent 50 minutes, excluding procedures, in critical care time examining the patient, evaluating the hemodynamic, laboratory. and radiographic data, developing a comprehensive management plan, and serially assessing the patient's response to our critical care interventions.

Procedures Name	Type	Pref List	Px Code
Critical Care Performed - Send to Coder		UNCHC IP PROFESSI...	CRITC
Critical Care Additional 30 Min	PR Charge	UNCHC IP PROFESSI...	99292
Critical Care E/M 30-74 Min	PR Charge	UNCHC IP PROFESSI...	99291

Responding to a SIGNIFICANT EVENT?¶

What is a Significant Event?¶

Rapid response
Code Blue
Clinical worsening
Bedsideevaluation
Need for urgent imaging, labs, therapeutics or consults

Don't forget to document! SIGNIFICANTEVENTNOTE¶

WAIT....did you perform critical care?