1. Communication is Vital! Technology is your friend!

2.  Accurate:  Observations only  Do not use subjective words  Correct spelling, grammar & med terms  Complete:  New or changed information  S/S, clients behavior  Nursing interventions  Meds given  Physicians orders carried out  Client teaching and response to therapy

3.  Consistent  Concise and brief using approved abbreviations  Objective  Important when documenting psychosocial and mental health issues  Legible  Writing must be clear and easily read by others  Line out errors: 100 cc clear yellow urine from foley  Organization  Use nursing process  Timelines  Document care, treatments, procedures and medications as soon as possible

4.  Purpose of documentation:  Communication  Assessment  Care planning  Quality assurance  Reimbursement  Legal documentation  Research  Education

5.  Technology in healthcare is advancing  Information will be managed electronically  Outcomes:  Safe patient care  Patient centered care  Improved outcomes  Ease of access to information  Workflow

6.  Federal Leadership for the Nationwide Exchange of Health Information  Funding for Infrastructure and Adoption of Health Information Technology  Privacy and Security of Personal Health Information

7.  Forms use a standardized language  Radio buttons, drop-down boxes  Data driven  Mandatory fields  Charting by exception  Increases compliance  Alerts to abnormal findings  Able to document all aspects of nursing care

8.  EHR/EMR  Monitoring  Imaging  Medication administration  Pharmacy  Clinical Decision Support Systems  ADT  CPOE  Central supply ordering systems

9. Elements that reduce human error:  CPOE  Bar Code  High Alert Medication Documentation  Point of Care Documentation  Mandatory Fields  Smart Pumps  Communication Tool

10.  Admission History and Assessment  Discharge Form  Nursing Care Plans  Flow Sheets/graphic sheets  Kardex  Clinical Pathways  Medication Administration Records (MAR)  Nursing Progress Notes  Patient education form  Acuity charting  Incident report Does NOT go in pt chart!

11.  Document only findings that fall outside of “normal”  Flow sheet with check boxes  Assessment findings, routine care activities  Narrative notes only when there is an exception or abnormal finding  Eliminates redundancy

18. Scanners Guardrail Library Multiple Channels

20. HIPAA

21.  Workflow  example: insulin administrationinsulin administration  How it applies to nursing:  Systems must support nursing workflow  Based on evidenced based practice  Nursing Process  Clinical Decision Support Systems  Built in safety checks  Promotes quality care

22. Pt has sliding scale order for regular insulin before meals and at bedtime Nurse checks pt. blood sugar Pt blood sugar: 250 (high) Pt blood sugar: 250 (high) Nurse reviews sliding scale and chooses insulin dose (6 units), prepares medication Insulin is a high alert med, so nurse must find another nurse and double check dose Nurse administers dose and documents on MAR Nurse also takes note of high blood sugar and orders a nutrition consult Nurse records pt. blood sugar Insulin administration workflow

23. Pt has sliding scale order for regular insulin before meals and at bedtime Nurse checks pt. blood sugar Pt blood sugar: 250 (high) Glucometer uploads results to pt chart and EHR generates referral for nutrition consult based on pts pattern of high blood sugars Pt blood sugar: 250 (high) Glucometer uploads results to pt chart and EHR generates referral for nutrition consult based on pts pattern of high blood sugars Nurse verifies uploaded blood sugar value and MAR automatically doses insulin based on standard sliding scale protocol Insulin is a high alert med, so nurse must find another nurse and double check dose Nurse administers dose and documents on MAR, second nurse verifies with barcode and password Nurse also takes note of high blood sugar and orders a nutrition consult Nurse records pt. blood sugar Insulin administration workflow

25. Purpose Techniques Content

26. Situation  Pt name  Age  Physician’s name  Diagnois  Hospital day/POD # Background  What brought them to the hospital  Past medical history

27. Situation Background Assessment Recommendation/ Request Often a framework for communication- calling MD, giving report, etc

28. Assessment  State what you think is the problem  Give review of symptoms Recommendation or Request  What needs to be done  What was done  Plan for discharge

29.  Information written in sentences or phrases usually time sequenced  Many combined with flow sheets  Not as effective data capture  Methods  SOAP  PIE  SOAPIER  Focus- DAR  SBAR

30. Led by Bellevue College, the Health eWorkforce Consortium was formed to elevate Health Information Technology workforce development locally and nationally and provide career paths into this promising field for veterans and others. The nine-college consortium includes Bellevue College, Bellingham Technical College, Clark College, Clover Park Technical College, Northern Virginia Community College, Pierce College, Renton Technical College, Spokane Community College, and Whatcom Community College. The Health Information and Management Systems Society (HIMSS) is also a primary partner. This workforce solution is 100% funded by an $11.7m grant awarded by the U.S. Department of Labor's Employment and Training Administration. The solution was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including, but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability or ownership. This work is licensed under a Creative Commons Attribution 4.0 International License. Exceptions: 1) Materials identified as copyrighted or derived from another source. 2) Materials extracted from the Office of the National Coordinator (ONC) Health Information Technology Workforce Curriculum, which carries a more limited CC-BY SA license.CC-BY SA license