![Page 1: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/1.jpg)
ASAP TJC (The Joint Commission) Scavenger Hunt
1
![Page 2: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/2.jpg)
Demographics: Ethnicity Open patients chart > Click on patients name > Contact Information
2
![Page 3: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/3.jpg)
Demographics: Race and Preferred Language
Open patients chart > Click on patients name > Clinical Information
3
![Page 4: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/4.jpg)
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
![Page 5: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/5.jpg)
Education: Learning Needs and Patient Education (ED Patient) cont.
Click search magnifying glass > Search education > Locate keywords in documentation
5
![Page 6: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/6.jpg)
Education: Learning Needs and Patient Education (Admitted Patient)
ED Narrator > Education > Boarder Education (cont.)
6
![Page 7: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/7.jpg)
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
![Page 8: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/8.jpg)
Nursing Assessments : Initial (Triage)
Triage > Rapid Intake or Primary Assessment
8
![Page 9: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/9.jpg)
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
9
![Page 10: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/10.jpg)
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
![Page 11: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/11.jpg)
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
![Page 12: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/12.jpg)
Nursing Assessments: Fall Risk Chart Review > SnapShot > Nursing Documentation > Locate Fall Risk Scale
FYI: Nurse may need to “wrench” in
Nursing Documentation
12
![Page 13: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/13.jpg)
Nursing Assessment: Abuse/Neglect
Chart Review > SnapShot > Nursing Documentation > Locate Domestic Violence Screening
FYI: Nurse may need to “wrench” in
Nursing Documentation
13
![Page 14: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/14.jpg)
Nursing Assessments: Suicide Risk
Chart Review > SnapShot > ED Encounter Details > ED Timeline
FYI: Nurse may need to “wrench” in ED
Encounter Details
14
![Page 15: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/15.jpg)
Nursing Assessments: Suicide Risk (cont.)
Click on search magnifying glass > Search Suicide > Locate keywords in documentation
15
![Page 16: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/16.jpg)
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
![Page 17: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/17.jpg)
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
![Page 18: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/18.jpg)
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
![Page 19: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/19.jpg)
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
![Page 20: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/20.jpg)
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
![Page 21: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/21.jpg)
Physician Documentation: Authentication of Orders
Orders > Active orders tab > Find the order > Hover order and click on paper
21
![Page 22: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/22.jpg)
Physician Documentation: Authentication of Orders (cont.)
Click on Blue link in Order Report > Box opens with order details
22
![Page 23: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/23.jpg)
Medication: Reconciliation
Orders > Home Meds
23
![Page 24: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/24.jpg)
Medications: Clarity of Orders
Orders > Active Orders tab > Look for comments in orders
24
![Page 25: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/25.jpg)
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
![Page 26: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/26.jpg)
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
![Page 27: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/27.jpg)
Procedural Documentation: Immediate Pre-induction Assessment
(ONLY Located in the Trauma Narrator) ED Narrator > Patient Summary > ED Encounter Details > Trauma Timeline > Checklist Performed
27
![Page 28: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/28.jpg)
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
![Page 29: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/29.jpg)
Procedural Documentation: Timeout
Chart Review > SnapShot > ED encounter Details > ED Timeline
FYI: Nurse may need to “wrench” in ED
Encounter Details
29
![Page 30: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/30.jpg)
Procedural Documentation: Timeout (cont.) Click search magnifying glass > Search Timeout > Locate keywords in documentation
30
![Page 31: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/31.jpg)
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
![Page 32: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/32.jpg)
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
![Page 33: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/33.jpg)
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
![Page 34: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/34.jpg)
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
![Page 35: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/35.jpg)
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
![Page 36: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/36.jpg)
Restraint Documentation: Orders
Orders > Precautions & Restraints
36
![Page 37: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/37.jpg)
Restraint Documentation: Monitoring
Chart Review > SnapShot > Search Restraints > Locate Restraint information
37
![Page 38: ASAP Scavenger Hunt - prd-medweb-cdn.s3.amazonaws.com · Demographics: Race and Preferred Language Open patients chart > Click on patients name > Clinical Information 3](https://reader031.vdocuments.us/reader031/viewer/2022022705/5bdb80ac09d3f2e0298c0f69/html5/thumbnails/38.jpg)
Restraint Documentation: Inclusion in Plan of Care
ED Narrator > Event Log > Look for Patient Goals that include restraints discontinuation
38