Charting a New Course for Nursing Documentation
Nov. 9, 2015 Update
Rollout Schedule:
Already live: Pediatric Acute Care Units ; Adult Acute Care Units in MCN and VUH
ICUs 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 Break
ICUs 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
See screen shot below with changes. Anything charted
Revised Documentation – there is a need to
against the old results will be viewable but not
standardize documentation of Bedside Blood
chartable.
Glucose monitoring
For Units using Revised Documentation – available in Train today and Production Wed. morning around
change of shift
1. Artificial Airway documentation available
Uses “site management” - style build.
2. it’s not efficient to have to go to several tabs to
New Frequent Interventions & Frequent Assessment
document elements that require documentation of sections bottom of Vitals/I&O tab to enable quick
assessment &/or interventions more frequently
documentation that need to be done more often than
than Q4h
Q4h
3. Inconsistency with location of devices.
4
& 5. For Peds ICU, they use percutaneously
inserted intracardiac catheters
6. Need to be able to document PVCs, PACs, etc.
7. Lack of clarity of meaning with pupil size and
reaction merged in one result.
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Of 4 pages total
All neuro “Devices” are now located only on the
Devices tab *(along with Cardiac Devices)
New line type for Peds only – “Intracardiac Cath” with
PA, LA, and RA options
Ectopic beats and Frequencies added to Cardiac
Assessment
Pupil size and reaction split out again
8. Need to document nursing care associated with
implanted vagal nerve stimulator
9, 10, & 11. Need way to document “return to normal”
for some assessment fields
12. Need to document air leak as part of Chest Tube
assessment.
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.
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
Caps
c. 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.
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.
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Vagal nerve stimulator assessment and interventions
added to Neuro Assessment and Interventions
sections
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.)
Added to Chest Tube Appearance drop down – “air
leak”
a. Neobladder and Nephrostomy added back
b. Voiding Alterations field added to
Assessments
C & 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
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
There is now a Misc. Goal to free text a goal if a “prefabbed” 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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1.
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