Inpatient Documentation

Severe Pathway

• RN/RT should speak at the beginning of the shift and decide on even vs odd hrs of assessment.
• All assessments need to be documented on the asthma flowsheet identifying the assessment and level of pathway.

Moderate Pathway

• RT does the assessments with treatments every 2 hrs and documents on asthma flowsheet in EHR.
• RN needs to be aware of the patient’s progress every 2 hrs.

A Child Transitioning from Moderate to Mild

• RT does assessment with treatments and documents on asthma flowsheet in EHR.
• RN needs to be aware of the patient’s progress every 2 hrs.
• If assessment indicates possible regression in pathway, RN should contact provider and RT to discuss. If regression is needed, RN should do full assessment on asthma flowsheet and highlight the assessment change as significant data.
• After one mild/moderate assessment with a treatment, the RT then does the second q2hr assessment and holds the treatment if appropriate. The RN then does the next hour (third hour) assessment and the RT does the fourth hour assessment with a treatment at the hospital acute dosing (weight-based) dose. Mild asthma pathway order sets are then entered at this time. All assessments and treatment given are documented on the asthma flowsheet in EHR.

Mild Pathway

• RT does the assessment and treatment every 4 hrs and documents on the asthma flowsheet.
• RN needs to be aware of the patient’s progress every 4 hrs.