HED Documentation Changes: Education Tab Safety/Fall Risk

Start With the Education Tab First Upon admission, identify the appropriate Care Contacts for your patient. This information needs only to be entered once during the admission (unless there is a change). The hover-over feature gives a precise description of the expected documentation to that area.

The Education Tab now follows the Priority Problems format. Identify who received your teaching as well as other pertinent information. If necessary, use the post-it note to annotate additional comments as usual.

Safety/Fall Risk Documentation In training region, there is a separate tab for Safety/Fall Risk documentation. This area of documentation will be embedded within the Assessment tab at go-live. FIRST, start at the top of the Safety/Fall Risk Assessment, and complete the Morse Fall Risk Screen. Morse Fall Risk Screen only gets done at admission, change in level of care/change in condition, post fall event The score will automatically tally for you Use the hover-over feature to help guide your documentation

Only need to document against applicable fields The Safety Risk Assessment and appropriate documentation need to be done every shift and PRN. Only need to document against applicable fields CIWA will also now be done in HED You can start a Priority Problem from here, if applicable. Now only need a Priority Problem if the safety issue is driving care or restraints in use Speak to safety issues in the Nursing Summary and Plan Priorities CIWA Scale found in the Assessment tab Score will display here as well

Restraint documentation, located within Section 2 is streamlined: Document the “Restraint Status” Checking “done” to “Restraint Safety and Comfort Care” reflects that you have done all the descriptors seen when using the hovering feature Document against both of these fields Q2H

Continuing down to Section 4…. If applicable, document who you notified regarding safety concern and what the plan is A new fall event is documented from here Take the time to go into HED Train from the desktop to look at these changes. In HED Train, there is a separate “Safety/Fall…” tab in which you can practice Go-Live for your unit will either be 10/16/12 or 10/23/12, depending on the unit. The “Safety/Fall…” tab will disappear, and this section will be embedded within the Assessment tab