Horizon Expert Documentation VUH Emergency Department

Learning Objectives  Identify workflow changes and processes that remain the same (i.e. order tracker, trauma documentation)  Locate and document assessment and interventions for Adult ED patients  Demonstrate use of HED to record care under the Adult ED Hourly tab  Verbalize understanding of the changes in documentation and workflow associated with new Falls/Safety HED build  For Admitted Patients, assign a plan of care in Starpanel, using a diagnosis specific pathway if available, or if not using a generic pathway.  Identify standardized priority problems, patient oriented short term goals, document an end of shift nursing summary and plan for next shift  Verbalize understanding of the changes in documentation and workflow associated with new Falls/Safety HED build 2

What’s changing, what’s not 3 Changing to HEDNot Changing Triage processX Trauma patientsX ED patient assessment Use Adult ED tab instead of StarPanel Nursing Assessment Hourly documentation Use Adult ED hourly tab instead of StarPanel Nursing Assessment Med AdministrationX Planning and managing care Priority Problems for Admitted Patients under plan of care tab in HED, save pathway to StarPanel Falls assessment/documentation Use Falls Risk/Safety documentation in HED for both ED and Admitted patients. Will no longer be in Social screening form. Stroke & STEMI documentationX (paper form now scanned)

New Patient  Scenario: Jane Doe, 58 y/o female with history of hepatitis, HTN, and anxiety brought into ED by family for c/o shortness of breath which has been going on for about a week but worse today. 4

Practice Scenario Scenario:  Patient brought to room C27 by wheelchair, ED property record completed. Patient complains of shortness of breath with exertion and anxiety  Vital signs 98.1 oral, Pulse 101, RR 20, BP 170/95, O2 sats 88% on room air, placed on 2L nasal cannula  Airway is patent. Dyspnea on exertion. Lung sounds are CTA.  Skin is warm, dry, and normal color. Mucous membranes are moist and Cap refills is less than 3 seconds  Heart rate is regular and pulses are 2+  Eyes open spontaneously, verbal response is oriented, and motor response obeys commands. Pupils are 4 mm and react briskly  Complains of pleuritic pain. Rates as 4 on 0 to 10 scale. Pain is sharp 5

Practice Scenario Interventions:  18 gauge PIV inserted in right cephalic vein on first attempt  Urine and blood obtained and sent to lab  Patient sent to ultrasound via stretcher with transporter  Plan of care: MD evaluation, medications, observation, diagnostic procedures & teaching 6

Adult ED Hourly Tab Scenario – Patient comes back from ultrasound and a brief assessment is done  Respirations are even and nonlabored  Skin is warm and dry  Resting with eyes closed. Opens eyes to speech, verbal response is oriented, opens eyes and follows commands.  Patient complains of lower back pain and rates pain 9/10. MD notified. Patient repositioned with pillows  Dilaudid given for pain, documented in Order Tracker 7

Learning Objectives  Identify workflow changes and processes that remain the same (i.e. order tracker, trauma documentation)  Locate and document assessment and interventions for Adult ED patients  Demonstrate use of HED to record care under the Adult ED Hourly tab  Verbalize understanding of the changes in documentation and workflow associated with new Falls/Safety HED build  For Admitted Patients, assign a plan of care in Starpanel, using a diagnosis specific pathway if available, or if not using a generic pathway.  Identify standardized priority problems, patient oriented short term goals, document an end of shift nursing summary and plan for next shift  Verbalize understanding of the changes in documentation and workflow associated with new Falls/Safety HED build 8

HED Changes with Safety/Falls New Safety/Fall Risk documentation: 1. New evidence-based Morse Falls Scale 2. Updated Safety and falls assessment sections 3. Restraints documentation simplified 4. New Education tab to capture specific topics and caregiver(s) contact information Morse Scale Restraints Education

Falls/Safety Documentation now in HED Scenario-  Complete Morse Fall risk screen: Patient has not fallen in the last 3 months Patient has multiple diagnoses Uses a cane Impaired gait Has IV access Knows own limitations/abilities 10

Priority Problems Documentation in HED v:training/neo/rn/2011/day111

Priority Problems for admitted/observation patients WHY?  We all have different ways of describing or talking about problems. You call it pain, I call it alteration in comfort  The decision was made to standardize how we talk about nursing care. The Clinical Care Classification* (CCC) Saba Model was selected  The Clinical Care Classification (CCC) System* is a standardized, coded nursing terminology that identifies the specific elements of nursing practice 12

Priority Problems: What to Do & When v:training/neo/rn/2011/day113 Admission Select & Save Pathway (StarPanel ) Document Phase (HED) Create 2-3 Priority Problems (HED) Beginning of Shift Review Pathway & Phase - change prn (HED) Document expected Short Term Goals for your shift (HED) End of Shift Document Short Term Goal Status or outcome (HED) Document Nursing Summary & Plan & Priorities for next shift (HED) Transfer/ Discharge Start/End Priority Problems. Change Pathway &/or Phase prn. Document Short Term Goal & status (HED) Document Nursing Summary and Plan & Priorities in HED

Choose the pathway that most closely reflects the expected patient progression. Usually the reason for admission. Specific pathways will have phases, goals and interventions that are a better fit. The evidenced based pathways can better guide care.  Medical Pathway – Pneumonia 1.Admission – Orders & interventions are aimed at achieving stabilization (improving airway clearance by suctioning, O2, antibiotics,...) 2.Stabilization - achieving controlled symptoms (fluid excess control, med mgmt for patients with chronic conditions) 3.Discharge – Ready for self-care; or care by another caregiver Admission Select & Save Pathway (StarPanel )

Priority Problems: What to Do & When v:training/neo/rn/2011/day115 Admission Select & Save Pathway (StarPanel ) Document Phase (HED) Create 2-3 Priority Problems (HED) Beginning of Shift Review Pathway & Phase - change prn (HED) Document expected Short Term Goals for your shift (HED) End of Shift Document Short Term Goal Status or outcome (HED) Document Nursing Summary & Plan & Priorities for next shift (HED) Transfer/ Discharge Start/End Priority Problems. Change Pathway &/or Phase prn. Document Short Term Goal & status (HED) Document Nursing Summary and Plan & Priorities in HED

Admission Document Pathway Phase (HED) Create 2 Priority Problems (HED) Definitions are located under “links” in HED.  Potential priority problems for Jane Doe: 1. Pain 2.Falls Risk 3.Airway Clearance Goals should be patient specific and measurable Such as “Pain less than 4 on a scale of 0-10”

Priority Problems: What to Do & When v:training/neo/rn/2011/day117 Admission Select & Save Pathway (StarPanel ) Document Phase (HED) Create 2-3 Priority Problems (HED) Beginning of Shift Review Pathway & Phase - change prn (HED) Document expected Short Term Goals for your shift (HED) End of Shift Document Short Term Goal Status or outcome (HED) Document Nursing Summary & Plan & Priorities for next shift (HED) Transfer/ Discharge Start/End Priority Problems. Change Pathway &/or Phase prn. Document Short Term Goal & status (HED) Document Nursing Summary and Plan & Priorities in HED

Priority Problems: What to Do & When v:training/neo/rn/2011/day118 Admission Select & Save Pathway (StarPanel ) Document Phase (HED) Create 2-3 Priority Problems (HED) Beginning of Shift Review Pathway & Phase - change prn (HED) Document expected Short Term Goals for your shift (HED) End of Shift Document Short Term Goal Status or outcome (HED) Document Nursing Summary & Plan & Priorities for next shift (HED) Transfer/ Discharge Start/End Priority Problems. Change Pathway &/or Phase prn. Document Short Term Goal & status (HED) Document Nursing Summary and Plan & Priorities in HED

Nursing Summary  Chart a brief synopsis of your shift before Shift change  Include major clinical events & information  For oncoming RN but does not replace face-to-face report  Prints on OPC as reference for nurse during shift Plan and Priorities for Next Shift  Your recommended plan and priorities for the oncoming nurse to address  Think of it as a “to do” list for the next RN  Keep it brief-240 character limit v:training/neo/rn/2011/day119