Charting a New Course for Nursing DocumentationNov. 9, 2015 Update

Rollout Schedule:

Already live: Pediatric Acute Care Units ; Adult Acute Care Units in MCN and VUHICUs Group 1 – PCICU, PICU, VCH; 10N, 11S, VUH (11-11-15 go live – NOTE -- this is a Wed.)ICUs Group 2 – 10T3, 9T3, 8T3 (11-17-15 go live) Thanksgiving Week BreakICUs Group 3 – 5N, 5T3 COBS, 6T3, 7T3, S54 Palliative Care (12-1-15 go live)EDs – Pediatric and Adult Inpatients boarding in the EDs (does NOT include documentation on Treat and Release patients) (12-8-15 go live)

Focus Topic for this Week: MANY Changes will go Live this week

There are two main categories of enhancements: 1) those required to ICUs (since our first group of ICUs goes live this week); 2) Those made in response to input from users on Adult and Pediatric Acute Care Units that have already gone live.

We approved additional changes that are not yet built so anticipate some more requests will be fulfilled over the next couple of weeks. We also reviewed some requests that were not approved but instead warrant education on new workflow.

For ICU units – since many completed LMS modules and/or attended Super-User training before the ICU design and “build” was complete, we want to be sure staff know what to expect as we go live with Documentation Revisions in our ICUs over the next month. Attached to the e-mail that included this document, please find a one page (legal sized page) mini-poster that addresses some key changes.

Issue, Concern, Request: Change:For ALL Units – including those not yet using Revised Documentation – there is a need to standardize documentation of Bedside Blood Glucose monitoring

See screen shot below with changes. Anything charted against the old results will be viewable but not chartable.

For Units using Revised Documentation – available in Train today and Production Wed. morning around change of shift1. Artificial Airway documentation available Uses “site management” - style build.2. it’s not efficient to have to go to several tabs to

document elements that require documentation of assessment &/or interventions more frequently than Q4h

New Frequent Interventions & Frequent Assessment sections bottom of Vitals/I&O tab to enable quick documentation that need to be done more often than Q4h

3. Inconsistency with location of devices. All neuro “Devices” are now located only on the Devices tab *(along with Cardiac Devices)

4 & 5. For Peds ICU, they use percutaneously inserted intracardiac catheters

New line type for Peds only – “Intracardiac Cath” with PA, LA, and RA options

6. Need to be able to document PVCs, PACs, etc. Ectopic beats and Frequencies added to Cardiac Assessment

7. Lack of clarity of meaning with pupil size and reaction merged in one result.

Pupil size and reaction split out again

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8. Need to document nursing care associated with implanted vagal nerve stimulator

Vagal nerve stimulator assessment and interventions added to Neuro Assessment and Interventions sections

9, 10, & 11. Need way to document “return to normal” for some assessment fields

For Strength, Movement, and Breath Sounds, there is now a “return to normal” option in drop down. This should be used ONLY if there was first an abnormal finding and the patient has improved. (Otherwise, just document WNL.)

12. Need to document air leak as part of Chest Tube assessment.

Added to Chest Tube Appearance drop down – “air leak”

13. Several issues noted with Renal/Urinary documentation:

a. Neobladder and Nephrostomy assessment fields missing

b. Can’t document burning on urination, bladder spasms, and similar

c. Need more interventions and change in the way they are organized.

a. Neobladder and Nephrostomy added backb. Voiding Alterations field added to

AssessmentsC & d. Revised Urinary Interventions to group all together as one drop down and deleted separate interventions for Urinary division, hemodialysis (which has it’s own tab), and In & Out Cath

14. Several issues with documentation of Education:a. Documentation of Care Contacts is still being

missed a lot.b. Staff confused by having EDUCATION in All

Capsc. We are required to review both Discharge Plan

and Plan of Care q shift.d. Learning strategies and Learner Engagement

being missed.e. Need option to document use of interpreter or

Language Line for Patient Education sessions.

a. Care Contact #1 is now force displayed and is shown in ALL CAPS – indicating this is a required field for all patients. If there is no Care Contact, you can document None.

b. Education & Engagement header and Education sub-header are now in mixed case as there is no requirement to document Education every single shift.

c. DISCHARGE/PLAN OF CARE REVIEWED is now in All Caps

d. The Learner Engagement and Education Comments result has been moved down from Discharge Plan section to right below the “Education” header.

e. Interpreter/Language Line now added as option in Learner Engagement drop-down

15. All Care Categories with problems do not have matching goals, so not possible to set a matching specific goal. i.e. Medication Risk Problem has no matching Medication goal.

There is now a Misc. Goal to free text a goal if a “pre-fabbed” goal does not exist.

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For access to FAQs, Training Information, and other Resources: http://www.mc.vanderbilt.edu/root/vumc.php?site=sss2&doc=47409

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