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Working draft to inform revisions to:Policy Title/#: Clinical Documentation: Inpatient Electronic- CL 30-05.16

PURPOSE: This policy outlines the minimum standards for nursing documentation for all Inpatient and Observation status Patients. Documentation reflects the nursing process and should protect the patient, the nurse, and the medical center by reflecting and communicating to the health care team a concise, accurate and meaningful record of care and patient response.

POLICY:For this policy, documentation requirements are defined as follows:

Documentation…

A. BASELINE: A comprehensive patient assessment will be documented within 24h of admission (or significant change in patient level of care) to establish patient physiological, functional, psychosocial baseline to inform the plan for care.

B. SHIFT: Standard inpatient assessments (displayed in caps) and those related to the individuals’ problem or risk of problems list shall be documented every shift followed by timely focused re-assessments of significant problems.

C. PLAN: The plan of care shall reflect prioritized problems, interventions, significant care team communications, plan changes, goals, patient response to care and discharge readiness.

D. DISCHARGE: A current shift assessment should be completed prior to discharge, problems needing follow-up should be identified and documented with a plan to address…

SPECIFIC INFORMATION:Patients are monitored in the inpatient setting according to the level of care required. Assessments, hands on care, teaching, counseling, and team communication may or may not be documented in the medical record depending on need for that information. This guideline is to ensure the nursing staff spends more time caring for the patient than documenting universal care standards.

The extent, frequency and timeliness of documentation depends on the importance of this information to inform team care decisions and support regulatory reporting. There are three levels of timeliness: (1) Real-time, (2) Near-time, and (3) Summative data. Real-time data captured by machine (e.g. Ventilator data , Barcoded meds, Glucometer) and is available immediately in the record. Manually transcribed machine data should be entered directly into record (VS). Near-time data (e.g. Neuro assessment, Restraint check) is documented as soon as reasonable, but no greater than 2 hours in ICU and 4 hours in acute care. The date/time should be adjusted to reflect the time the assessment or intervention was done (resulting in time stamps for time done and time entered). Summative data reflects non- time

1 DRAFT last updated 8/9/2015 1:48:00 AM (DA)

sensitive information and can be done at any time to reflect previous assessments and interventions done this shift. Nurses make copy their own assessment documentation up to 72 hrs

DEFINITIONS:

Goals – One to two short term measureable goals are set for priority problems early in the shift. Outcomes of these goals are described in the patient Response to Care narrative summary.

Care Categories - Physiological (Cardiac, Neuro), Functional (Activity, Nutrition), and Psychosocial (Coping, Safety) groupings that organize the assessments & interventions that reflect nursing practice. (Exhibit A)

Standards of Care - “Every patient every time. “Reflect standards of practice and provide a guide to the knowledge, skills, judgment and attitudes that are needed to practice safely. They are (1) considered as the baseline for quality nursing care; (2) developed in relation to the law governing nursing practice; (3) applicable to the registered nurse practicing in any setting at all levels of practice. http://www.hg.org/article.asp?id=6237

Nursing Process - The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care. It includes: Assessment, Nursing Diagnosis (Problems) , Outcomes/Planning, Implementation & Evaluation. http://www.nursingworld.org/especiallyforyou/studentnurses/thenursingprocess.aspx

Response to Care – Patient response to interventions, progress against goals and plan changes. Modified Charting by Exception – To reduce repetitive charting of normal assessment detail ,

nurses chart within normal/expected limits (WNL, WEL) for each care category omitting normal findings except for normal values needed for decision support (Braden, Morse, RASS). Findings that are outside expected limits (OEL) require supporting documentation (eg tachycardia).

o WNL – Within normal limits. Meets standard criteria for developmental age o WEL – Within expected limits. Does not meet all the standard criteria for development age,

but is expected for patients in this clinical phase (post-op) or normal for patient and does not require measures beyond the standard of care.

o OEL – Outside expected limits - Does not meet criteria for WNL or WEL (eg. agitated), but has not risen to the level of a problem. No additional, special care except include in next focused assessment. Some notation of what parameter is OEL in a key data field (eg RASS = 1) or associated comment (pt c/o dizziness). Temporary foley catheter.

o Problems (Nursing diagnoses) require targeted interventions and should be a significant focus of the plan of care (eg. Incision)

o Priority problems Priority problems are flagged in red and represent the most important shift focus based on patient (eg pain), team (eg oxygenation) and nurse’s assessment of risk (eg skin integrity) . They require measureable goals and outcomes are described in the Response to Care narrative statement.


http://www.nursingworld.org/especiallyforyou/studentnurses/thenursingprocess.aspx

http://www.hg.org/article.asp?id=6237

Interventions – Reflect implementation of the plan of care (Assess, Care, Teach, Notify) based on provider orders, VUMC Policy & Procedure, and published Nursing standards of care (ie Mosby).

DOCUMENTATION PROCEDURES

All care categories require documentation on admission. Assessments shown in all capital letters are required documentation every shift. Focused re-assessment is done if the initial assessment for that category was outside expected limits or if the patient unstable, is at risk for, or has an existing problem for that care category. Assessments are problem focused, meaning that the nurse will assess whether the patient presents as Within Normal limits (WNL), Within Expected Limits (WEL), Outside Expected Limits (OEL), or has a Nursing diagnosis (problem or problem risk) needing focused monitoring and/or care

TABLE 1 - REQUIRED ASSESSMENTS (X)

CARE CATEGORY ADM QSHIFT + FOCUSED REASSESSMENT

- PAIN X X if problem/risk- NEURO X X if problem/risk- CARDIAC X X if problem/risk- Vascular/Perfusion X if problem/risk- RESPIRATORY X X if problem/risk- GASTROINTESTINAL X X if problem/risk- SAFETY/FALL RISK X X if problem/risk- SKIN/WOUND X X if problem/risk- URINARY/RENAL X X if problem/risk- Activity/Musculoskeletal X if problem/risk- Fluid/Nutrition X if problem/risk- Medication X if problem/risk- Infectious/Metabolic X if problem/risk- Psychosocial X if problem/risk- Reproductive OB if problem/risk- Self-care (ADL) X if problem/risk

Admission History & Baseline Assessment

Document a baseline against which to evaluate changes in patient physiological, functional, developmental and behavioral health status within 24 hr. This includes pertinent medical, procedural and medication history as well as home medical equipment, therapies and duration of therapy. Initiate high risk screening as warranted/ required (influenza, sleep apnea, nutrition, abuse, pregnancy risk, lactation). Special populations require additional screening (e.g. OB, neonate, psych). Note significant conditions and devices present on admission (e.g. pressure ulcer, CVC) not already noted. Any cultural or religious considerations should be noted if relevant. Initiate individualized plan of care based on findings. This builds on the Adm Hx assessment completed in StarPanel (Exhibit B

Shift assessment


Assessments (including devices) shall be documented every shift AND with change in level of care. If instability or risk exists, additional assessments may be required. In addition, the nurse will document data required for approved population based decision supportC (Braden PU Risk, Glascow Coma Scale) or data to meet current regulatory requirementsD.

Abnormal Signs & Symptoms: Patients assessed as outside expected limits or with problems (skin integrity impairment) should have supporting signs & symptoms (coccyx red, heel blister) recorded. Normal values (skin dry & intact) should not be charted as they are documented at the care category level (Skin WNL or OEL).

Focused Re-assessment

Once the initial shift assessment is done, focused reassessments are documented as warranted based on orders and/or patient condition. If the patient is stable in some or all categories (except Pain), the nurse documents ONLY that the reassessment was either Unchanged, or Unchanged except, noting only the exception. See example below:

Figure 1 - Reassessment (HED) example

etc..

Abnormal, unexpected findings or patients with significant risk of problems may merit further assessment and intervention. Interventions include monitoring, treatment as ordered and those within scope of practice, patient and family education referrals/ escalation as warranted. Findings of risk will dictate the frequency of the focused assessment.


INTERVENTION DOCUMENTATION

Interventions include four action types: (1) Monitoring, (2) Direct care, (3) Patient & family education and (4) Care Team communication.

Interventions are performed (1) as prescribed in the current plan of care, (2) according to VUMC policy if applicable, and/or (3) published nursing care standards (Mosby) within the TN Nursing Scope of Practice.Documentation of interventions detail is not required unless it is needed to inform future care decisions such as conveying special techniques or frequency of documentation. This can be done through annotations.

Example:

Respiratory intervention: Tracheostomy care; ties & dsg changed Neuro intervention: Seizure precautions ; room darkened, side rails padded

A list of common interventions, expected timeliness, and references are available in Appendix E.

Intervention documentation timeliness (example)

Action Intervention Document Guideline (if not prescribed)Monitoring Vital Signs Real-time Mosby SkillDirect Care Trach care Q Shift Mosby SkillDirect care Med administration Real-time CL 30-06.01Direct care Pressure ulcer prevention Near-time CL 30-09.01Direct care Seizure precautions Near-time Mosby SkillEducation Pacemaker education Q Shift Krames – AdultCommunication Notify HO if temp > Near-time -


Monitoring & Direct CareMonitoring and direct care will be implemented at a level and/or intensity appropriate to the patient (Peds, OB, Elderly, etc.) and follow prescribed care, VUMC Policy, or an evidence based standard (Mosby

Care team communication

Significant discussion with members of the healthcare team should be reflected in the Communication/Event Note . The note should include who was notified and why, as well as the outcome of the discussion.

SCREEN LAYOUT (ROWS & TABS)

The organization layout of the documentation screens in HED generally reflects workflows (VS , Med Admin) in the tabs across the top, and Care Categories (which change according to tab) rows in the left hand navigation panel. The Plan of Care is the landing page when documentation begins in order to review current patient status (problems, goals, outcomes).

CARE CATEGORIES (ROWS)

WORKFLOWS (TABS)

Protocol tabThe protocol tab supports complex decisions that rely on data from multiple care categories for special, at risk populations such as substance abuse withdrawl. See CIWA AppendixF

Documentation tabs

The organization of the documentation screens in HED generally reflects workflows (VS , Med Admin) in the tabs across the top, and Care Categories (which change according to tab) rows in the left hand navigation panel. The Plan of Care is the landing page when documentation begins in order to review current patient status (problems, goals, outcomes).

PLAN VS/IO+ PARTNER ASSESS INTERVE ADMINR

X PAIN/CDR TEACH DEVICE ALL DOC-

- PAIN APHERESIS

- NEURO ASSIGN

- CARDIAC DIALYSIS

- Vascular/Perfusion ECMO/CRRT

- RESPIRATORY POCT

- GASTROINTESTINAL TRANSFUSE

- SAFETY/FALL RISK ETC

- SKIN/WOUND- URINARY/RENAL


- Activity/Musculoskeletal- Fluid/Nutrition- Medication- Infectious/Metabolic- Psychosocial- Reproductive- Self-care (ADL)- PAIN

Seq TAB – NAME view FULL NAME/ PURPOSE1 PLAN 12h PLAN OF CARE - Consolidated view of problems, goals,

interventions, patient response to care and readiness for discharge. Also significant events and/or care team communications.

2 VS/IO+VS/IO_4h

1h,4h

VITAL SIGNS_INTAKE & OUTPUT + MONITORED DATA (DAS), PEWS, MEWS (future)+ INTERVENTIONS?

3 PARTNER 4h CARE PARTNER – One tab for all data entry by care partners4 ASSESS1

ASSESS41h,4h ASSESSMENTS/PROBLEMS - Less scrolling with interventions

removed5 INTERVENTION 1h INTERVENTIONS/PROCEDURES - includes complex procedure w/

significant charting that also have its own tab (ECMO, CRRT…)6 ADMINRX 1h MEDICATIONS - Medications, immunizations… Related drug

teaching7 PAIN/CDR 1h PAIN + CONTROLLED DRUG RECORD8 TEACHEDUCATION 24h PATIENT EDUCATION & ENGAGEMENT

Support System (Care Contacts), language, understanding, willingness and ability to participate in therapeutic plan related to condition or procedure. Includes Discharge readiness related to knowledge deficit and non-adherence.

9 DEVICE 1h COMPLEX MECHANICAL DEVICE requiring extensive documentationIe IABP, CRRT, DIALYSIS

9 A/D/T 24h ADMISSION/DISCHARGE/TRANSFEREstablishes baseline. Contains all the elements required on admission, internal transfer, and/or discharge to home or other facility. Includes post-mortem data

10 ALL DOC- 12h ALL DOCUMENTATION – Assessments, Interventions, Education, Plan

11 RISKPROTOCOL 1h RISK SCORING – Infrequently done risk scoring whose many elements fall across care categories. - NAS, WATS, CIWA, PEWS, MEWS?

ALPH SORT


AAPHERESIS 1h APHERESISASSIGN PATIENT ASSIGNMENTDIALYSIS 1h HEMODIALYSIS & PERITONEAL DIALYSISECMO/CRRT 1h ECMO, CRRTPOCT 4h POINT OF CARE TESTINGTRANSFUSE 15m BLOOD & BLOOD PRODUCT TRANSFUSIONETC ETC

View is the default timescale with which to view trended data.


Patient & Family education

Patient & Family education is an ongoing process and part of our care standards. Documentation is focused on the outcomes of education, rather than the individual components of a teaching session.

reflects the the data elements noted in the table below:

Diagnosis & Procedure Exhibit _ Patient & Family Education


LEARNER(S) EXAMPLE Developer guidelinePREFERRED LANGUAGE SpanishPreferred learning mode VideoInterpreter Name or ID# 87657Care Contact 1 Name1 Anna Perez Care Contact 1 Role Spouse Care Contact 1 Language English Care Contact 1 tel # 615-222-1234Care Contact 2 Name2…etcEDUCATION & ENGAGEMENTDischarge Plan Reviewed doneDISCHARGE READINESS Knowledge deficitKnowledge Deficit MedicationEducation/Engagement goal understands drug precautions Goals match knowledge,

skill and adherence problems

Learner engagement (session) CC1 Tbk, videoEducation comments:EDUCATIONHandout(s) (annotate)* HF bifoldHospital Orientation Medication education Anticoaguants: Warfarin AHFS ClassesNutrition/Fluid education\ Low Na diet, 1000ml fluidPain Mgmt educationSafety education CPR, EMSSkin care educationTobacco cessation education DX/PROC** Krames folder structureCardiac education Heart Failure, BP ControlGI educationInfectious disease educationMental Health educationNephrology educationNeuro educationOB/GYN educationOncology educationOrthopedic educationPulmonary educationSTD education

1 Care Contact 1-5 (CC1) Once a person is noted as CC1, CC2, etc their number should not be changed during the course of the stay. If they are the primary caregiver – select that with their role (spouse). If no longer relevant – select role as “Remove from list”.2 Care Contact 1-5 (CC1) Once a person is noted as CC1, CC2, etc their number should not be changed during the course of the stay. If they are the primary caregiver – select that with their role (spouse). If no longer relevant – select role as “Remove from list”.


Surgery – General educationUrology educationVascular educationLEARNERS EXAMPLE

PREFERRED LANGUAGE SpanishPreferred learning mode VideoInterpreter Name or ID# 87657Care Contact 1 Name Anna Perez

Care Contact 1 Role Spouse Care Contact 1 Language English Care Contact 1 tel # 615-222-1234

etcEDUCATION & ENGAGEMENT

Knowledge Deficit Education/Engagement goal Spouse understand warfarin precautionsLearner engagement (session) CC1 Tbk, videoEducation comments:

EDUCATIONHandout(s) (annotate)*: HF bifoldHospital Orientation Medication education Anticoagulants: WarfarinNutrition/Fluid education Low Na diet, 1000ml fluid restrictionPain Mgmt educationSafety education CPRSkin care educationTobacco cessation education

DX/PROC**Cardiac education Heart Failure, BP ControlDiabetes educationGI education Infectious disease educationMental Health educationNephrology educationNeuro educationOB/GYN educationOncology educationOrthopedic educationPulmonary educationSTD educationSurgery – General educationUrology education Vascular education

Exhibit _ Admission History Exhibit - Admission History


Exhibit _ Protocol TabThe protocol tab supports complex decisions that rely on data from multiple care categories for special, at risk populations (e.g. withdrawl). Each protocol should have an associated policy reference which is linked to the HED under its logical care category and which is referenced in the hover text in the final score. Each protocol element is preceded by its common abbreviation (CIWA: Nausea) to indicate that there is a protocol specific definition which will appear in the hover. This will help ensure inter-rater reliability, especially when common terms are used. With the exception of the shared Vitals Signs, the row order is alphabetic by abbreviation. Abbreviations have clarifying text.

| PROTOCOLS | VITAL SIGNS CIWA - Alcohol withdrawal CNSDP - VPH CNS depressant withdrawal COWS - Opiate withdrawal MEWS – Modified Early Warning Score PEWS – Pediatric Early Warning Score WATS – Pediatric withdrawl assessment

-VITAL SIGNSBLOOD PRESSUREHEART RATEPAIN SCORERASSRESPIRATIONSTEMPERATURE

- CIWA - ALCOHOL WITHDRAWL [Hover text]CIWA Score (auto-calc)

auto CIWA = Clinical Institute Withdrawl Assessment for Alcohol. A CIWA score along with a treatment protocol can prevent under or over-treating patients with benzodiazepines in patients with alcohol withdrawal. Related policy link> MEDICATION > CIWA PROTOCOL >

CIWA: Temperature 0= Less than 98.7 1= 98.7 – 99.5 2= 99.6 – 100.4 3= greater than 100.4

CIWA: Pulse 0= Less than 90 1= 90-95 2= 96-100 3= 101-105 4= 106-110 5= 111-120 6= greater than 120

CIWA: Diastolic BP 0= Less than 95 1= 95-103 4= 104-112 6= greater than 112

CIWA: Respirations 0= Less than 20 1= 20 – 24 2= greater than 24

CIWA: Nausea/vomiting

Ask 'Do you feel sick to your stomach? Have you vomited?'

CIWA: Tremors Arms extended and fingers spread apart

CIWA: Anxiety Ask, 'Do you feel nervous?'

CIWA: Agitation Observed

CIWA: Sweats Observed

CIWA: Orientation Ask 'What day is this? Where are you? Who am I?

CIWA: Tactile Disturbances

Ask, 'Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?'

CIWA: Auditory Disturbances

Ask, 'Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?'

CIWA: Visual disturbances

Ask 'Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?'

CIWA: Headache Ask 'Does your head feel different? Does it feel like there is a band around your head?' Do not rate


for dizziness or lightheadedness. Otherwise, rate severity

- MEWS – Early Warning Score

value

Drop down single select list or hover

MEWS Score (auto-calc)

auto Notify MD if >3 - 4 or greater will turn red. Source: http://www.ihi.org/resources/Pages/ImprovementStories/EarlyWarningSystemsScorecardsThatSaveLives.aspx

MEWS: Respiratory Rate

20123

o < 8o 9-14o 15-20o 21-29o >29

MEWS: Heart Rate 210123

o <40o 40-50o 51-100o 101-110o 111-129o >129

MEWS: Systolic BP 32102

o <70o 71-80o 81-100o 101-199o >200

MEWS: Urine output 3210

o < 10 ml/hro <30 ml/hro <45 ml/hro >45 ml/hr

MEWS: Temp 21012

o <35C or ?Fo 35.1-36Co 36.1-38Co 38.1-38.5Co 38.6 C

MEWS: Conscious level

3210

o Unresponsiveo Responds to pain onlyo Responds to voice or New agitation/Confusiono Alert

Modified Early Warning Score

The scores for each parameter are recorded at the time that observations are taken. If the total is 4 or more then the ward doctor is informed.


A CCC Care Categories & DefinitionsB Admission HistoryC Nursing Documentation needed for Clinical Decision SupportD Nursing Documentation needed for Regulatory Requirements E Documentation frequencyF Protocol: CIWA

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