1. Electronic Controlled Drug Record (CDR) in

2. At the end of this tutorial, the nurse will be able to: Identify the need for electronic documentation of IV controlled medications Summarize process for the documentation of and cosignature requirements of IV controlled substances within HED Identify processes when paper CDR will still be required

3. Need for Change CDR documentation practices varied across units – need for standardized approach Corrections needed to CDR were time consuming and disjointed – nurse may not be working or available to make corrections Auditing and review process in electronic medical record left room for improvement

4. What’s Changing Blank CDRs will no longer be available in AcuDose with meds. CSLs will have in locked drawer Documentation of all requirements elements will be under new CDR tab in HED, including cosignature For areas, not using HED CDR documentation, paper CDR will be used in handover Blank CDRs will no longer be available in AcuDose with meds. CSLs will have in locked drawer Documentation of all requirements elements will be under new CDR tab in HED, including cosignature For areas, not using HED CDR documentation, paper CDR will be used in handover Assessment of patient under sedation or on pain medications Documentation of the following will still take place in HED: –IV Intake –IV drip rates Assessment of patient under sedation or on pain medications Documentation of the following will still take place in HED: –IV Intake –IV drip rates What’s NOT Changing NEW

5. Don’t forget to Co-Sign!! Start Infusion *Also used for new bag 1.Enter dose of med and rate 2.Enter concentration found on drug label and select started 3.Enter volume primed – HED will auto calculate a left to count 4.Have RN cosign at bedside

6. Drug Label The drug concentration to be entered in HED can be found on the medication label. Locate priming volume on packaging of IV

7. Charting Specifics Chart every 4 hour charting (or per unit standard): Dose & rate and Intake Chart hold status: Note when a medication is being held and why

8. Annotate if Left to Count is not zero: “Wasted amount measured & witnessed by 2 RNs as per protocol” Don’t forget to Co-Sign!! Stop Infusion 1.Enter concentration from drug label and select “stopped” from dropdown 2.Use last “left to count” number and enter this as “Volume to Start” 3.Enter “volume wasted” – HED will auto calculate a left to count 4.Have RN cosign at bedside all of the fields

9. Reminder: Clear pumps at the end of each shift or per unit standard *When reporting to another area using HED CDR End of Shift/ Handover Report During handover report the nurse should chart volume at start and cosign.

10. If you receive a patient with a paper CDR, follow the Start Infusion instructions using the CDR amount as Amount at Start. – Annotate “See HED for CDR documentation” – Paper CDR should remain in the chart – When receiving patients from Anesthesia providers, it is acceptable to cosign with licensed RN on unit If you transfer a patient to another area, you must transcribe Left to Count from HED to the CDR. – Annotate “See HED for CDR documentation” – Paper CDR should be given to the transfer unit Transfer to area not using HED CDR Tab

11. RacfID is required to co-sign in real time. Co-Signing

12. When & Where to Cosign When Where

13. If you do not know your RacfID or password, please call the Help Desk at (3-HELP) to have your RacfID password reset prior to the pilot. To reset your VunetID password click the following link: http://its.vanderbilt.edu/epassword/http://its.vanderbilt.edu/epassword/ RacfID Password Reset

14. Effective December 2, 2014 System Support Staff will be providing 24/7 onsite support. If you have questions or need assistance: Call the Help Desk at 343-4357 (3-HELP)

15. Start Drug, dose, concentration, start volume, primed volume entered. Co-sign required. New Bag, Rate Change, Hold Correct drug, dose, concentration, infusion rate & pump settings verified by 2. Co-sign required. Q4h Amount infused (dose, intake, volume @ start, volume infused). No co-signature needed. Handover/ Change of Shift Correct drug, dose, concentration, infusion rate & pump settings verified. Pump cleared q12 h. Co-sign required End Drug status: “stopped”; volume @ start, volume wasted. Co-sign required. Transfer from/ to Paper CDR area Sending to paper CDR unit: transcribe “left to count” from HED to CDR & send paper CDR to receiving unit. Note “See HED for CDR documentation” on CDR. Receiving paper CDR: follow “Start” instructions above; place paper CDR in paper chart. Note “See HED for CDR documentation” on CDR. Tip Sheet – Print and Keep