1. Charting a New Course for Patient Documentation
Super User Training

2. What You Will Learn Today
Upon completion of training, the learner will demonstrate ability to: 1. Share the vision for the changes in nursing documentation 2. Identify at least 2 “Myths” that have been barriers to documentation reduction in the past and verbalize an effective response to both 3. Complete a documentation scenario without assistance 4. Verbalize 3 expectations of a Super User during unit implementation 5. Identify 5 resources available to all staff to support transition to the new documentation processes 6. Demonstrate 3 techniques most likely to be effective in promoting peer adoption of the changes.

3. The Super user role is vital to implementation of this change!
THANK YOU
The Super user role is vital to implementation of this change!

4. PUT VALUE BACK INTO WHAT NURSES DOCUMENT
Charting A New Course for Patient Documentation
Why chart a new course?
Nurses need more time with their patients and to spend less time writing about what they are doing with their patients!
This pie chart is the amount of time nurses spend doing various activities from time studies that were conducted. – what are we doing the most- Documentation a whopping 35%
It is clear that nurses need more time with their patients and to spend less time writing about what they are doing with their patients
The documentation revisions project kicked off to re-distribute the pieces of pie.
Nursing documentation is very important to patient care. You guys are really telling the story of the patient. So we wanted to be sure we told this story well. Just cutting out fields in HED doesn’t help you tell the story better. Documentation is also there to help support other disciplines – providers, RT, PT, Dieticians, SW, etc….
Shifting our thought to value – how to we make sure everything that the nurse is documenting is valuable and contributes to that story and informs the care you and others give
So just cutting out the time isn't the entire goal – we are putting value back into what nurses document
If we get into how we define value itself – value is quality/cost. So for you guys it would be (equation). Meaning there is a balance. Every minute is important. Every field should be important.
PUT VALUE BACK INTO WHAT NURSES DOCUMENT
With revisions, need to assure that everything that the nurse is documenting is valuable and contributes to the patient story and informs the care you and others give.

5. Not designed to be everything to everyone
FOCUS
Targeted design for the proficient, ethical nurse
Not designed to be everything to everyone
The new documentation is being designed for use by proficient, ethical nurses so we will be challenging old thinking that often resulted in added documentation to address performance issues of very small numbers of low performers. This additional documentation burden penalized all nurses and often did not achieve the desired outcomes of bringing deficient practice up to standard. These old ways of thinking about documentation are very ingrained so during this initial communication period, one of our biggest opportunities is “myth busting”.

6. STOP!!! Stop documenting MOST normal values
Stop charting data no one looks at or uses
Stop duplicate documentation
Stop transcribing data from devices
To save time we must…
Stop documenting MOST normal values
Stop charting data no one looks at or uses
Stop duplicate documentation
Stop transcribing data from devices.

7. What would you do…..
If you had minutes time back per shift due to less time spent on documentation, what would you be able to do with your patients and families during that time that you cannot do now?
Allow time for learners to call out answers…. Impt that they be able to verbalize this to others as they are role modeling this as a super user.

8. Myth Busters
So if we all agree that we want to put value back in our documentation and spend more time with the patient vs writing what hold us back…. Why is it so hard to change. Some of the reason is that there are some belief that are held that are just not correct. Much of the transition to this new process will involve changing the culture and some deeply held beliefs and challenging misconceptions.
We need you to be the myth busters….

9. “If it’s not charted, it’s not done.”
“I have to chart this because it’s required by … “ [Joint Commission, Hospital Policy, Risk Management, etc.]
If it’s not Charted, its not done. – Risk Management tells us this is just not true. ( DO WE HAVE A VIDEO RESOURCE FOR THIS??)
“I have to chart this because it’s required by … “ [Joint Commission, Hospital Policy, Risk Management, etc.]
Joint Commission standards require certain outcomes – for example, screening for nutritional risk factors that would warrant a consult to a Dietician – BUT they do not mandate what that screening process looks like or specify what must be documented. The same is true of many regulatory requirements. They generally want us to follow our own policies. Our documentation policies are about to change drastically and one big outcome from that will be a reduction in quantity of documentation required.
“Quantity of documentation = quality of care I provide” if I don’t document a lot it doesn’t look like I worked hard. This is not nursing school where you get a better grade the longer your care plan is .
We know that changing long-standing, deeply held beliefs is not just about facts. We also have to understand the emotions and values associated with those beliefs. We need staff to BELIEVE that changing their documentation is NOT going to negatively impact the quality of care their patients receive.
What other documentation myths should we add to this list?
“Quantity of documentation = quality of care I provide”

10. We are reducing documentation in order to increase nurse to patient ratios or make other staffing changes.
NOT TRUE!
No further changes are planned to the staffing models. Documentation reductions are needed to make the model work better.
We are reducing documentation in order to increase nurse to patient ratios or make other staffing changes
NOT TRUE!
We already made the staffing model changes and the documentation changes are needed to make those staff model changes work better.

11. Many levels of nursing were involved in developing the revisions.
Those making all these changes are out of touch with what really happens at the bedside- these changes will never work.
NOT TRUE!
Many levels of nursing were involved in developing the revisions.
Those

12. “Real Nurses” were involved.
“Real Nurses” were involved
Here is a list of the various committee members that have worked on these changes… these are real nurses giving input and making decisions about revisions

13. What is NOT changing: Care Organizer & Admin-Rx
General format of HED screens and way to select items from drop down menus or typing annotations
Nursing Admission History still in StarPanel
Clinical Care Classification (CCC) standardized terminology for documentation of problems
Required documentation denoted by ALL CAPS
Concept of Priority Problems/ goals
What is NOT changing:
Care Organizer & Admin Rx
General format of HED screens and way to select items from drop down menus or typing annotations
Nursing Admission History will continue to be documented in Star Panel
Clinical Care Classification (CCC) standardized terminology for documentation of problems
Required documentation denoted by ALL CAPS
Concept of Priority Problems/ goals

14. Patient Scenario Wheezes present in BLL Patient is asthmatic
Pt admitted with complaints of a deep and productive cough for 1 week with progressively worsening yellow phlegm.
Wheezes present in BLL
Patient is asthmatic
Admission dx is pneumonia
Pt reports hx of asymptomatic AFib X 5 yrs
Patient small stage 1 PU on left buttock
Hypoactive BS
You receive the pt from the ED with antibiotics infusing in r forearm 20 G PIV
Other than respiratory issues the patient healthy

15. The Nit and the Grit of the changes
Sign on to CWS w/ your id
Click HED train icon
Use the training patient on your card
Sign on to CWS and Click HED train icon.
In the training region you will see both the current tabs as well as the new tabs.
The new tabs are in ALL CAPS.
The tabs after implementation will be
Plan
Vitals/I&O
Assessment
Interventions
Devices
Education

16. New Tabs & Order
In the training region you may see both the current tabs & new tabs.
In Live HED, the PLAN tab will load 1st
Most of the new tabs are in ALL CAPS

17. Old VS New Tabs
Most of the new tabs will be in ALL CAPS but there are some existing tabs that are in ALL CAPS too ( i.e. CRRT) that will continue to be used as we transition.
There are also some tabs that are used now that will transition over that are not in all caps – i.e. Blood transfusion, chemo, Pain/CDR.
On the chart menu, there will also be the tabs for the areas that are not being implemented in this first phase ( i.e. NICU, OB)

18. Pain Documentation
In Live HED, you will see reduced fields for pain documentation:
Reassessment of pain is documented with a new score
Pain documentation requirements have NOT changed, there are just less fields to document on. Refer to Policy Tech for more details.

19. Pain Interventions Will not be found in the Assessment tab
Can be found in Interventions, All Doc, Pain/CDR, or AdminRx.
New options:

20. Learner Engagement
In HED Live, you will see Learner Engagement (session)

21. Protocols Tab
New Protocols Tab including CIWA, etc.

22. Nursing Documentation Guidelines Review

23. Tips for ALL DOC The following items can be found in ALL DOC:
If you can’t find an item, go to ALL DOC & use the Add button to search
The following items can be found in ALL DOC:
Transfer & transport
Isolation Precautions (or in Interventions)
Co-Sign (for students)
Downtime
Use the “Add” button to search for items in All Doc

24. Discharge
Discharge Plan of Care Reviewed, Discharge Readiness and Discharge Problems needing follow-up have been moved from the  Assessment/Problem section to the Plan of Care section on the PLAN Tab & the Education tab.
A current shift assessment should be completed prior to discharge, problems needing follow-up should be identified and documented with a plan to address.

25. When to Document What…

26. Display of Data
Currently, most of the documentation is displayed in a real time view. Some spend a lot of time adjusting times they document to be at the top of the hour so the data aligns in a single column, making viewing info easier.
With the revisions, the displays of the data has been collapsed to facilitate easy viewing.
Data displays in 1 hour increments
VS/I&O
Assessment
Interventions
Pain/CDR
Device
Protocols
Displays in 12h increments
Plan
ALL DOCS
Displays in 24h increments
Education
Click Chart to see the actual Documentation Times

27. Shift to Shift Handovers
Use the Plan tab to facilitate handovers. It should capture the patient story.

28. Training and Implementation
Manager presentation to staff
For Super Users….
Attend SU class
Complete LMS
Complete unit based practice scenario
Staff….
LMS
Complete Unit Practice. As Super User f/u to see that they have completed and offer help with the unit based practice scenario.
GO LIVE
Sept 15: Pilot 8N & 8S, VCH 8
Oct 13: 5S, 6S, 7N, CTU, 7S
Oct 20: 10S, S34, S44, S64, S74, CRC
Oct 27: VCH 6th & 7th floors
Nov 3: 11N, 9N, 9S, 6N, 7S (?)
Nov 11: PICU, PCICU, 10N, 11S **NOTE on Wed**
Nov 17: 8T3, 9T3, 10T3
Dec 1: S54, 5N CVICU, COBS, 6T3, 7T3
Dec 8: Adult ED, Peds ED
(Excluded: NICU/ Newborn Nursery, VPH, ED, OB, Periop and procedural areas & areas that don’t document in HED)
Support
1 Super User each shift on each unit for the first week
SSS 24X7 for 5 days
(covering multiple units)
Round and assist staff
**Review charting **
Trouble shoot OB
NICU & Newborn Nursery
Psych
ED treat & release patients
Operative and Procedural patients
Areas that do not document in HED

29. Transitioning from Old to New
GO LIVE DAY
Tech team will push the new tabs to HED “LIVE” by 0700
Day shift will begin using the new tabs
To view previous charting, toggle back to the “old tabs” from the tabs drop down menu or via the chart option in the top tool bar

30. Expectations of a Super User during unit implementation:
Role & Responsibility
Expectations of a Super User during unit implementation:
At the Elbow Support to Nursing Staff ( answering ?s and coaching)
Review Documentation via chart audits and follow up with users for any issues
Report problems/Issues
Roll model completion of ALL 4 LMS modules and Unit Practice Scenario
Follow-up with staff assigned to you to encourage and track completion of LMS modules and Unit Practice
Communicate to Manager any concerns about readiness of staff assigned to you

31. Resources

32. Resource
Resources available to all staff to support transition to the new documentation processes
Hover Overs/ Links in HED (Krames)/ Mosby
Nursing Documentation Policy
Job Aide
Super User Guidelines for Nursing Documentation Support
Systems Support Nursing Education Website
FAQ
Debriefing sessions
Colleagues on the documentation committee/ SSS /Educators
Help Desk
What Else???

33. Online Resources Click icon on desktop or link on VUMC webpage
Type SSS in main VUMC webpage and select System Support Services to get our webpage.

34. TAKE CARE OF THE PATIENT, then worry about charting!
Promoting Adoption
Demonstrate 3 techniques most likely to be effective in promoting peer adoption of the changes.
Timing
Approach
Follow-up
TAKE CARE OF THE PATIENT, then worry about charting!

35. Timing Is Everything…
Would you approach a nurse or staff member in the following situations?
In the break room?
At the accudose machine?
Two nurses discussing the upcoming weekend?
A care partner running with a crash cart?
A nurse near a room with visibly
upset family?
A nurse providing care?

36. Approach Coach/ mentor – non punitive
“ I am touching base with all RNs to see how charting is going with the new system. It’s a big change and I am here to help. What did you think? Did you have any questions or concerns.
Then give feedback… I noticed “…..”
Do not give a huge list of issues- prioritize
It will take a lot of coaching and practice

37. Approach (cont.) More Direct Phrases to add to your collection
“Can you tell me a time when I can come back?”
Check with charge nurse for best times to return considering typical unit workflow patterns

38. Follow up Denote all ?s/Concerns and seek out answers Prioritize
Investigate
Triage

39. What’s wrong with this picture??
Admission Assessment
Only chose 1-2 Priority Problems
Only set goals for those 1-2 priority problems
Chart ALL categories on admission
Annotate WEL on admission
Make sure there is supporting data for OEL
Is it WEL (baseline) or OEL?

40. What about “difficult” users
Role Plays- divide up into pairs or sm groups. Pass out each of the 5 role play exercises.

41. Strategies Do’s Don'ts Be comforting not confrontational.
Let’s summary what you learned… What are some dos and don’t’s
Be comforting not confrontational. I know it’s hard and it take more time right now. I understand your frustration.
What else???
Be comforting not confrontational.
“I know it’s hard and it takes more time right now.”
“I understand your frustration.”

42. Expectations of a Super User during unit implementation:
Role & Responsibility
Expectations of a Super User during unit implementation:
At the Elbow Support to Nursing Staff ( answering ?s and coaching)
Review Documentation via chart audits and follow up with users for any issues
Report problems/Issues
Roll model completion of ALL 4 LMS modules and Unit Practice Scenario
Follow-up with staff assigned to you to encourage and track completion of LMS modules and Unit Practice
Communicate to Manager any concerns about readiness of staff assigned to you

43. Repeat after me…. SUPPORT CREDO
I am responsible for getting this fixed, and for documenting the problem and its solution.
I understand that people are frustrated and angry, but I won’t take their anger personally.
I will empathize with the frustration that my peers feel, and tell them that I understand and share their feelings.
I will calm them down with my words and manner.
I will not accept abuse.
I will not blame the user.

45. Next Steps Complete the LMS modules
Complete a Unit Practice ( on your own)
From your manager/educator, get list of staff you are coaching (approx 10)
Communicate to SSS any concerns or questions
PLAY in HED train