1. Charting Tips for HED Nursing Documentation Changes
Admission
Priority Problems
WEL
OEL
Is this a new admission? * Yes: Must chart in all Care Categories (Except reproductive/ Lines if not applicable) * No: Only need to address Care Categories in CAPS and if applicable
Are your priority problems red?
Only Need 1-3
Usually one goal per priority problem (sometimes one goal can cover two problems eg. O2 Sat Goal may relate to Cardiac and Respiratory problem)
Is this a new admission? * Yes: Must annotate why WEL * No: Ensure that admitting nurse annotated reason for WEL. If so, no need to annotate again!
Ask yourself: *is this WNL or WEL? *Has this risen to the level of a problem?
If not, consider OEL. (Required Supporting documentation may be Annotation or other Assessment documentation in that Care Category.)
Don’t forget to chart those interventions! Let’s take credit for what nurses do!