Education Tab Safety/Falls Risk under Peds Assess/Intervention

The Education Record 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. 3

Start With the Education Record 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. 4

 Safety assessment on every patient, every shift.  Falls Screen o Adults: Morse Falls screen o Peds: Humpty Dumpty Falls o on admission, q shift, and with condition changes o Streamlined documentation of Restraint Safety Care  Safety Problems (Injury Risk, Violence Risk, Substance Abuse, and others) will be identified. o If a safety problem will be a key driver of nursing care for that patient, also initiate as a Priority Problem o CIWA documentation will be available in HED for units that implement CIWA protocol  Safety Interventions will be documented – things you: o Assess/Monitor/Evaluate/Observe o Care/Perform/Provide/Assist o Teach/Educate/Instruct/Supervise o Manage/Refer/Contact/Notify

Peds Falls Assessment Score Auto-Calculates  Peds Falls assessment score will be auto calculated  Continue to chart Falls Risk Assessment Interventions for Standard or High Risk 8

The Safety Risk Assessment and appropriate documentation need to be done every shift and PRN.  Only need to document against applicable fields  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  Document Response to Safety Interventions in Nursing Summary and Plan Priorities at end of shift 10

NEW Safety/Fall Risk Documentation Below Peds Falls Assessment, the new Safety Risk Assessment will display to incorporate everything related to Safety:  Peds Falls assessment will be auto calculated  Falls Risk Assessment included  NEW Safety Assessment to be completed qshift  Safety Monitoring  Safety Care Implemented  Safety Education/Engagement  Safety Notification/Care Coordination 12

Contributors to fall or injury risks

Interventions for falls risk patients

Interventions for violence/injury

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 17

 1. All patients are on Standard Falls Precautions_____  2. Falls risk assessment is done on admission and at discharge_____  3. You will now be able to chart falls events on the falls/safety tab____  4. For high risk falls patients, interventions could include: ambulating with the patient, monitoring medication side effects, keeping the room cleared, having the patient to wear yellow socks and yellow armband, and placing LAMP sign on the patient’s door ______  5. You can only start a safety/fall priority problem on the poc tab_____  6. Safety assessments are done q day_____