Electronic Controlled Drug Record (eCDR) in

eCDR Overview Controlled Drug Record documentation will be completed in HED instead of on the paper CDR. Paper CDR will only be used for transfers into or out of areas not using CDR in HED or during downtime. Epidural infusions will remain on paper CDR at this time. New CDR tab in HED.

Palliative Care Pilot 8/12/14 Burn & PICU Pilot 9/23/14 SICU & 9S 9/15/14 VCH 6A 1/20/15 VUH Towers 2/10/15 VCH 2/24/15 eCDR Timeline Jan ‘15 Feb ‘15 Aug ‘14 Sept ‘ CCT, MCN & 4E 2/17/15

Don’t forget to Co-Sign!! Start Infusion

Drug Label The drug concentration to be entered in HED can be found on the medication label. Locate priming volume on packaging of IV

Don’t forget to Co-Sign!! New Bag/Syringe

Charting Specifics

Annotate if Left to Count is not zero: “Wasted amount measured & witnessed by 2 RNs as per protocol” Don’t forget to Co-Sign!! Stop Infusion

Don’t forget to Co-Sign!! Reminder: Clear pumps at the end of each shift or per unit standard *When reporting to another area using HED CDR End of Shift/ Handover Report During handover report the nurse should chart volume at start and cosign.

RacfID is required to co-sign in real time. Co-Signing

What’s Changing Blank CDRs will no longer be available in AcuDose with meds. Call pharmacy if a paper CDR is needed Documentation of all requirements elements will be under new CDR tab in HED, including cosignature For areas, not using HED CDR documentation, paper CDR will be used in handover Blank CDRs will no longer be available in AcuDose with meds. Call pharmacy if a paper CDR is needed Documentation of all requirements elements will be under new CDR tab in HED, including cosignature For areas, not using HED CDR documentation, paper CDR will be used in handover Assessment of patient under sedation or on pain medications Documentation of the following will still take place in HED: –IV Intake –IV drip rates Assessment of patient under sedation or on pain medications Documentation of the following will still take place in HED: –IV Intake –IV drip rates What’s NOT Changing NEW

When & Where to Cosign When Where

If you receive a patient with a paper CDR, follow the Start Infusion instructions using the CDR amount as Amount at Start. – Annotate “See HED for CDR documentation” – Paper CDR should remain in the chart & be scanned into EMR If you transfer a patient to another area, you must transcribe Left to Count from HED to the CDR. – Annotate “See HED for CDR documentation” – Paper CDR should be given to the transfer unit Transfer to area not using HED CDR Tab

If you do not know your RacfID or password, please call the Help Desk at (3-HELP) to have your RacfID password reset prior to implementation. To reset your VunetID password click the following link: RacfID Password Reset

System Support Staff will be providing 24/7 onsite support. If you have questions or need assistance: Call the Help Desk at (3-HELP) VUH Tuesday 2/10/15 MCN, CCT & 4E Tuesday 2/17/15

Start Drug, dose, concentration, start volume, primed volume entered. Co-sign required. New Bag, Rate Change, Hold Correct patient, drug, dose, concentration, infusion rate & pump settings verified by 2. Co-sign required. Q4h Amount infused (dose, intake, start, volume infused). No co-signature needed. Handover/ Change of Shift Correct patient, drug, dose, concentration, infusion rate & pump settings verified. Pump cleared q12 h. Co-sign required End Drug status: “stopped”; start, volume wasted. Co-sign required. Transfer from/ to Paper CDR area Sending to paper CDR unit: transcribe “left to count” from HED to CDR & send paper CDR to receiving unit. Note “See HED for CDR documentation” on CDR. Receiving paper CDR: follow “Start” instructions above; place paper CDR in paper chart. Note “See HED for CDR documentation” on CDR. Process for Controlled Drug Record Charting in HED CDR Tab