Charting Tips for HED Nursing Documentation Changes Admission Priority Problems WEL OEL Is this a new admission? * Yes: Must chart in all Care Categories (Except reproductive/ Lines if not applicable) * No: Only need to address Care Categories in CAPS and if applicable Are your priority problems red? Only Need 1-3 Usually one goal per priority problem (sometimes one goal can cover two problems eg. O2 Sat Goal may relate to Cardiac and Respiratory problem) Is this a new admission? * Yes: Must annotate why WEL * No: Ensure that admitting nurse annotated reason for WEL. If so, no need to annotate again! Ask yourself: *is this WNL or WEL? *Has this risen to the level of a problem? If not, consider OEL. (Required Supporting documentation may be Annotation or other Assessment documentation in that Care Category.) Don’t forget to chart those interventions! Let’s take credit for what nurses do!