asap scavenger hunt - prd-medweb-cdn.s3.amazonaws.com · demographics: race and preferred language...
Post on 02-Nov-2018
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ASAP TJC (The Joint Commission) Scavenger Hunt
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Demographics: Ethnicity Open patients chart > Click on patients name > Contact Information
2
Demographics: Race and Preferred Language
Open patients chart > Click on patients name > Clinical Information
3
Education: Learning Needs and Patient Education (ED Patient)
Chart Review > SnapShot > ED Encounter Details > ED timeline
FYI: Nurse may need to “wrench” in ED
Encounter Details
4
Education: Learning Needs and Patient Education (ED Patient) cont.
Click search magnifying glass > Search education > Locate keywords in documentation
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Education: Learning Needs and Patient Education (Admitted Patient)
ED Narrator > Education > Boarder Education (cont.)
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Education: Learning Needs and Patient Education (Admitted Patient) cont.
Assessment and Education tab
FYI: Green filled in circle with white check mark is complete; Green empty circle with green checked mark is initiated; Orange circle is not yet resolved 7
Nursing Assessments : Initial (Triage)
Triage > Rapid Intake or Primary Assessment
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Nursing Assessments: Initial (Triage) cont. Use side by side view > Highlight patient > Triage tab > Scroll through triage information
Use above arrow to get side by side
view
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Nursing Assessments: Ongoing Chart Review > SnapShot > Nursing
Documentation > Scroll down to find assessments
More > Flowsheets > Assessments OR
FYI: Nurse may need to “wrench” in
Nursing Documentation
10
Nursing Assessment: Nutritional Screening (Admitted Patients Only)
Chart Review > SnapShot > Nursing Documentation > Locate Nutrition Screen
FYI: Nurse may need to “wrench” in
Nursing Documentation
11
Nursing Assessments: Fall Risk Chart Review > SnapShot > Nursing Documentation > Locate Fall Risk Scale
FYI: Nurse may need to “wrench” in
Nursing Documentation
12
Nursing Assessment: Abuse/Neglect
Chart Review > SnapShot > Nursing Documentation > Locate Domestic Violence Screening
FYI: Nurse may need to “wrench” in
Nursing Documentation
13
Nursing Assessments: Suicide Risk
Chart Review > SnapShot > ED Encounter Details > ED Timeline
FYI: Nurse may need to “wrench” in ED
Encounter Details
14
Nursing Assessments: Suicide Risk (cont.)
Click on search magnifying glass > Search Suicide > Locate keywords in documentation
15
Nursing Assessment: Pain Assessment/Reassessment
Chart Review > SnapShot > ED Encounter Details > Locate Vitals section
FYI: Nurse may need to “wrench” in ED
Encounter Details
16
Nursing Assessments: Advanced Directives
Open patients chart > Click on patients name > Advance Directives tab
FYI: Information on Advanced Directives can be found in the header
17
Nursing Assessments: Advanced Directives (cont.)
Chart Review > SnapShot > Pt Sum > Advanced Directives
FYI: If patient has Advanced Directives on file, click the blue hyperlink to view 18
Physician Documentation: History and Physical
Chart Review > Notes > Click Type > Choose H&P for this encounter
FYI: Clicking on “Type” will alphabetize the notes and make
items easier to locate
19
Physical Documentation: Consult Notes
Chart Review > Notes > Click Type > Locate Consult notes
FYI: Clicking on “Type” will alphabetize the notes and make
items easier to locate
20
Physician Documentation: Authentication of Orders
Orders > Active orders tab > Find the order > Hover order and click on paper
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Physician Documentation: Authentication of Orders (cont.)
Click on Blue link in Order Report > Box opens with order details
22
Medication: Reconciliation
Orders > Home Meds
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Medications: Clarity of Orders
Orders > Active Orders tab > Look for comments in orders
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Procedural Documentation: Informed Consent
Chart Review > Media tab > Click Document type > Look for Consent
FYI: Clicking on “Document Type” will alphabetize the notes and make items easier to locate
25
Procedural Documentation: Pre-anesthesia Assessment
Chart Review > Notes tab > Click Type > Look for Anesthesia Pre-procedure
FYI: Clicking on “Type” will alphabetize the notes and make
items easier to locate
26
Procedural Documentation: Immediate Pre-induction Assessment
(ONLY Located in the Trauma Narrator) ED Narrator > Patient Summary > ED Encounter Details > Trauma Timeline > Checklist Performed
27
Procedural Documentation: Pre-procedural checklist
Chart Review > SnapShot > Nursing Documentation > Under Nursing Procedures, look for Pre-Op Checklist
FYI: Nurse may need to “wrench” in
Nursing Documentation
28
Procedural Documentation: Timeout
Chart Review > SnapShot > ED encounter Details > ED Timeline
FYI: Nurse may need to “wrench” in ED
Encounter Details
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Procedural Documentation: Timeout (cont.) Click search magnifying glass > Search Timeout > Locate keywords in documentation
30
Procedural Documentation: Post-anesthesia Assessment
Chart Review > Notes tab > Click Type > Anesthesia Post-procedure
FYI: Clicking on “Type” will alphabetize the notes and make
items easier to locate
31
Ancillary Documentation: Discharge Planning (Admitted Patients)
Use side by side view > Search discharge > Locate Discharge planning notes > Click on note to open report
Use above arrow to get side by side
view
32
Ancillary Documentation: Respiratory Therapy Highlight patient name on trackboard > Use side by side view > Click Reports tab > Search for RT therapies
33
Use above arrow to get side by side
view
Ancillary Documentation: PT/OT
Chart Review > Notes tab > Look for PT/OT
FYI: Clicking on “Type” will alphabetize the notes and make
items easier to locate
34
Ancillary Documentation: Social Work
Chart review > Notes > Type > Locate Social Worker notes
FYI: Clicking on “Type” will alphabetize the notes and make
items easier to locate
35
Restraint Documentation: Orders
Orders > Precautions & Restraints
36
Restraint Documentation: Monitoring
Chart Review > SnapShot > Search Restraints > Locate Restraint information
37
Restraint Documentation: Inclusion in Plan of Care
ED Narrator > Event Log > Look for Patient Goals that include restraints discontinuation
38
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