objectives: hed nursing documentation

Document Interventions, Assessments

Set Preferences & Create Assignment

View Confirming Med Orders

Commit to use HED system safety

checks

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Beginning of shift or change level of

care

Items in ALL CAPS on gray bar charted

each shift

Line Manage charted each shift

Vanderbilt charts to Standards & only

denotes variances

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Brief synopsis of your shift before Shift change

Include major clinical events & information

For oncoming RN..does not replace face-to-face report

Prints on OPC as reference for nurse during shift

Temp controlled with Tylenol. No further nausea. O2

sats improved on nasal cannula.

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Explore StarPanel.. EMR◦ Look up test results and documents

◦ Complete Admission History form

◦ Assign a Pathway (Plan of Care)

Enter orders in HEO/Wiz… CPOE◦ Enter Nursing Orders for New Admission

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3 Sections of Admission Data

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Duplicate Name alert

Inpatient Admission

Observation Admission (short term stay) Patient has discharge orders

Pre-Orders entered by Provider for Chg Nurse or MR to playback today      

P

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Processing of OrdersProcessing of Orders

Orders & Reqs print to Medical Receptionist (MR) and

placed in unit appropriate area

MR: Notifies RN of STAT Orders and Labs

MR: Notifies Department of Other Tests

RN: Acknowledges Orders online

Emergency Departments: Order do NOT print. Lab

Requisitions generate to printer closest to pt’s room

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Steps to Acknowledge Orders

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