Horizon Expert DocumentationHorizon Expert DocumentationVUH Emergency DepartmentVUH Emergency Department
Learning Objectives Identify workflow changes and processes that remain the same (i.e. order tracker, trauma documentation)
Locate and document assessment and interventions for Adult ED patients
Demonstrate use of HED to record care under the Adult ED Hourly tab
Verbalize understanding of the changes in documentation and workflow associated with new Falls/Safety HED build
For Admitted Patients, assign a plan of care in Starpanel, using a diagnosis specific pathway if available, or if not using a generic pathway.
Identify standardized priority problems, patient oriented short term goals, document an end of shift nursing summary and plan for next shift
Verbalize understanding of the changes in documentation and workflow associated with new Falls/Safety HED build
2
What’s changing, what’s not
3
Changing to HED Not Changing
Triage process X
Trauma patients X
ED patient assessment Use Adult ED tab instead
of StarPanel Nursing
Assessment
Hourly documentation Use Adult ED hourly tab
instead of StarPanel
Nursing Assessment
Med Administration X
Planning and managing
care
Priority Problems for
Admitted Patients under
plan of care tab in HED,
save pathway to
StarPanel
Falls
assessment/documentati
on
Use Falls Risk/Safety
documentation in HED
for both ED and Admitted
patients. Will no longer
be in Social screening
form.
Stroke & STEMI
documentation
X
(paper form
now scanned)
New Patient
Scenario:
Jane Doe, 58 y/o female with history of hepatitis, HTN,
and anxiety brought into ED by family for c/o
shortness of breath which has been going on for about
a week but worse today.
4
Practice ScenarioScenario: Patient brought to room C27 by wheelchair, ED property record
completed. Patient complains of shortness of breath with exertion and anxiety
Vital signs 98.1 oral, Pulse 101, RR 20, BP 170/95, O2 sats 88% on room air, placed on 2L nasal cannula
Airway is patent. Dyspnea on exertion. Lung sounds are CTA. Skin is warm, dry, and normal color. Mucous membranes are moist and
Cap refills is less than 3 seconds Heart rate is regular and pulses are 2+ Eyes open spontaneously, verbal response is oriented, and motor
response obeys commands. Pupils are 4 mm and react briskly Complains of pleuritic pain. Rates as 4 on 0 to 10 scale. Pain is sharp
5
Practice Scenario
Interventions:
18 gauge PIV inserted in right cephalic vein on first attempt
Urine and blood obtained and sent to lab
Patient sent to ultrasound via stretcher with transporter
Plan of care: MD evaluation, medications, observation,
diagnostic procedures & teaching
6
Adult ED Hourly Tab
Scenario – Patient comes back from ultrasound and a brief assessment is
done Respirations are even and nonlabored Skin is warm and dry Resting with eyes closed. Opens eyes to speech, verbal
response is oriented, opens eyes and follows commands. Patient complains of lower back pain and rates pain 9/10. MD
notified. Patient repositioned with pillows Dilaudid given for pain, documented in Order Tracker
7
Learning Objectives Identify workflow changes and processes that remain the same (i.e. order tracker, trauma documentation)
Locate and document assessment and interventions for Adult ED patients
Demonstrate use of HED to record care under the Adult ED Hourly tab
Verbalize understanding of the changes in documentation and workflow associated with new Falls/Safety HED build
For Admitted Patients, assign a plan of care in Starpanel, using a diagnosis specific pathway if available, or if not using a generic pathway.
Identify standardized priority problems, patient oriented short term goals, document an end of shift nursing summary and plan for next shift
Verbalize understanding of the changes in documentation and workflow associated with new Falls/Safety HED build
8
HED Changes with Safety/Falls
New Safety/Fall Risk documentation:
1. New evidence-based Morse Falls Scale
2. Updated Safety and falls assessment sections
3. Restraints documentation simplified
4. New Education tab to capture specific topics and
caregiver(s) contact information
Morse
Scale
Restraints
Education
Falls/Safety Documentation now in HED
Scenario-
Complete Morse Fall risk screen:• Patient has not fallen in the last 3 months• Patient has multiple diagnoses• Uses a cane• Impaired gait• Has IV access• Knows own limitations/abilities
10
Priority Problems Documentation in HED
v:training/neo/rn/2011/day1 11
Priority Problems for admitted/observation patients
WHY?
We all have different ways of describing or talking about problems. You call it pain, I call it alteration in comfort
The decision was made to standardize how we talk about nursing care. The Clinical Care Classification* (CCC) Saba Model was selected
The Clinical Care Classification (CCC) System* is a standardized, coded nursing terminology that identifies the specific elements of nursing practice
12
Priority Problems: What to Do & When
v:training/neo/rn/2011/day1 13
Choose the pathway that most closely reflects the expected patient progression. Usually the reason for admission. Specific pathways will have phases, goals and interventions that are a better fit. The evidenced based pathways can better guide care.
Medical Pathway – Pneumonia1. Admission – Orders & interventions are aimed at achieving stabilization (improving airway
clearance by suctioning, O2, antibiotics, . . .)2. Stabilization - achieving controlled symptoms (fluid excess control, med mgmt for patients with
chronic conditions)3. Discharge – Ready for self-care; or care by another caregiver
Admission•Select & Save Pathway (StarPanel )
Priority Problems: What to Do & When
v:training/neo/rn/2011/day1 15
Admission
•Document Pathway Phase (HED) •Create 2 Priority Problems (HED)
Definitions are located under “links” in HED.
Potential priority problems for Jane Doe:
1. Pain2.Falls Risk3.Airway Clearance
Goals should be patient specific and measurable
Such as “Pain less than 4 on a
scale of 0-10”
Priority Problems: What to Do & When
v:training/neo/rn/2011/day1 17
Priority Problems: What to Do & When
v:training/neo/rn/2011/day1 18
Nursing Summary
Chart a brief synopsis of your shift before Shift change
Include major clinical events & information
For oncoming RN but does not replace face-to-face report
Prints on OPC as reference for nurse during shift
Plan and Priorities for Next Shift Your recommended plan and priorities for the oncoming nurse to address
Think of it as a “to do” list for the next RN
Keep it brief-240 character limit
v:training/neo/rn/2011/day1 19