Vanderbilt Psychiatric Hospital
Electronic Medical Record:
Unit Resource Manual
01/15/10
Vanderbilt Medical Center
Systems Support Services
VPH: Electronic Medical Record
• Why? Patient Safety – improved documentation
(comprehensive assessment, content, &
legibility), Bar-Coded Med Administration
• What? HED for RN & MHS charting, StarPanel
forms, & Admin Rx (med admin)
• When? Pilot on Adult I begins January 18th & all
other units “Go Live” on February 1st
• How? Support Model: SSS staff will be on
site to round 1st week of pilot & 2 weeks
post – Go Live
Which Paper Documentation
Processes will be continued?
Electronic Conversion
expected Spring 2010
• Respond Crisis Assessment
• Social Work Psychosocial
Assessment & Progress Notes
• Teacher Progress Notes
• Treatment Plan
• Respond Crisis Intake
Paper Format Indefinitely
• All Restraint &
Seclusion
Documentation
• Patient Belonging Sheet
• Patient Discharge
Instructions Sheet
HED Basics
Click on HED icon on the desktop & enter
Racf ID (Id to enter CWS) opening to Care
Organizer. Click on HED to document.
Select your patient by clicking the
arrow, then find them in the drop
down list.
A few pointers before we begin to Enter Data:
•Pt demographics at the top of the screen (make sure you selected the correct pt)
•Read the screen left -> right
•Some tabs for charting are customized to your location
•Make sure your Number lock is activated on your keyboard
Click the tab you want to
enter data on. VPH view will
contain 8 tabs:
•VPH Assess/Intervention
•VPH Vitals & I/O
•MHS Observation
•Protocols
•VPH Education
•Observation Precautions
• Admin Rx
•Pain
To begin entering data, click on the CHART
button.
This will “open” your chart for
data entry
If needed,
change time
here.
If this tab has been previously charted
on, only those fields that contained data
will re-open to be charted in.
Click Show All to see all fields available
for data entry (this should be done at
least once a shift).
Begin entering data in the open fields.
Some will have a drop down
with one selection to be made
Some have drop downs with
check boxes (more than one
item may be selected). If an
item is chosen in error, simply
click again to de-select.
0.4
Some fields will have keyed in
data entry
100
As with this Transitional Checklist, some
are a simple check that an item is done.
To enter general comments, click in the
box and type in comments. Note: 250
character max.
To make an annotation concerning a
single entry, click the “sticky note” on
the corresponding line
Enter the comment (250 character max)
“Sticky note will turn yellow. Hover over
it to see the comment.
Notice the yellow check mark
on the tab-this is reminding you there is unsaved data on this tab.
Do NOT exit without saving or this data will be lost.
Once data entry is complete,
you are ready save.
You will be taken to the Confirm Screen.
Verify patient is correct, time of entry,
and data correctly entered.
Click Confirm to save data
to chart.
Use the Back button to return
to charting if mistakes are
found.
Use the Discard button when
you want to clear all data
entered (use if incorrect
patient).
CopyCannot be copied:
•Numerical data
•Annotations/ comments
•Other people’s data
•>30 hours old (works for
same patient multiple days
•All or nothing (can edit
what you copied)
•ECMO fs-only select items
can be copied
Copy/Modify/Move/Clear
Functions-with the chart
“closed” click in the space
between the date and time
of the column selected.
ClearCan clear entire column or
select portions at one time
(useful if you charted on
the wrong pt)
ModifyCan modify single or
multiple data points at one
time
MoveCan move entire column of
data to another time
(useful if you forgot to
change your time on the
chart screen)
RN: VPH
Assessment/Intervention Tab
RN: VPH Assessment/Intervention Tab:
Note some fields are labeled with a job title and some with NO Job title
1. RN = RN to document. RN ONLY field = clinical assessment in the RN scope of practice or
the drop down options are clinical assessment findings (not observations) as in MHS
2. MHS = MHS to document
3. NO Job Title = Both RN & MHS can document with the same drop down options
4. This functionality is secured via the employee’s ID & HED Application Support Team
Safety Opportunity:
+ Psych pts are guarded
with symptomology & do
not share symptoms with
all staff.
+ Clinical findings of RN &
MHS can be viewed by each
discipline.
+ RN can view ALL MHS
documentation
+ MHS views only RN’s
documentation of General
Behaviors, Hallucinations, &
all of the Risk Assessment.
RN: Mental Status Exam
Annotate to provide more detailed information – see example below “CIA is after me!”
Click on
to open text field to type in your comment.
RN/MHS: Behavioral Intervention
1. Select Intervention (“continue to monitor” should be routinely chosen w/ other
interventions added as indicated)
2. Select patient’s response
RN/MHS: Risk Assessment Section
• In this section, you will assess & document
clinical findings for:
– Suicidal Behavior
– Self Harmful Behavior
– Violent Behavior
• Safety Opportunity: It is vital for RN’s & MHS’s to
review the clinical findings & observations of
their counterparts. Note: The pt may have shared
Suicidal thoughts with MHS but NOT the RN!!!
RN: Risk Assessment – Suicidal Behavior
1. Risk Factors for Suicide = “What places your patient at higher risk of acting on suicidal thoughts/
ideation?” (such as family hx, hopelessness, lives alone)
2. Describe Plan is a narrative entry field
3. Protective Factors = “What aspects of your patient’s life will help protect them from acting on
suicidal thoughts/ideation?”
4. Safety Plan is REQUIRED on ALL patients that have identified risk for Suicide –drop down options
include “continue to monitor”, “notify staff”, & “other w/ annotation”
1
2
3
•RN Assessment must ALWAYS address Risk Factors & Protective
Factors for Suicide. (Even if NO suicidal ideation is present!!)
•Patients with Risk Factors for Suicidal Behavior MUST have a Safety
Plan & Interventions
RN/MHS: Risk Assessment – Self-Harm
1. Select Behaviors exhibited
2. Interventions to be completed ONLY if Self-Harmful behaviors are present
Self Harmful behavior is either present or NOT. If NOT present,
there is NOT a necessity to create a safety plan or interventions.
Suicidal & Violent Behaviors are more unpredictable & the
presence of risk requires PROACTIVE INTERVENTIONS to
protect the pt & others.
RN: Risk Assessment - Violence
•Violence Risk & Risk Factors must be completed on ALL pts
•Patients at Risk REQUIRE a Safety Plan & Interventions
RN: Precautions
1. In the paper documentation workflow, the RN Documents level of PRECAUTIONS
for the pt on the “Sticky Note”. This is where it will be documented in HED.
2. NOTE: Hourly documentation of mental health precautions are documented in the
Observation Tab by either the RN or MHS (will cover in Precautions Observation Tab)
RN: Nutrition, Sleep, ADL’s, & Protocols
Note: Detailed Protocol Documentation will be done in Protocols Tab
RN: Transport/Transfer
1. To document transport/transfer to VUH for medical care & Court
2. Document patient’s return to unit
Upon return to VPH,
documentation of return should
occur in this field
RN: Involuntary/Voluntary Section
1. Document change in Legal Status (to involuntary status or to voluntary status) & the
notification of RESPOND
2. Court Hearing & Findings
3. Treatment Review Committee – document when requested & TRC determination when
committee meeting is held
As this section will be used only
occasionally, click “Show All” to
locate in the Gray Bar
RN: Falls Risk Assessment
Complete with EACH RN ASSESSMENT
1. Identify Risk Factors for Falling
2. Assessment level of Risk – Standard or High
3. Document Risk Prevention – Standard Risk Interventions for ALL pts – High Risk pts
= Standard + High Risk Interventions
RN: Pain Assessment
(located in both Pain Assessment Tab & VPH
Assessment/Intervention Tab)
Complete EVERY SHIFT
Scroll down to enter
Pain Relief Goal.
Within 2 hours of
intervention, need to
reassess for patient’s
response
RN: Medical Problem Documentation
Document on an “as needed” basis determined by the patient’s clinical condition
Consult your nursing leaders for guidance on this type of documentation
RN: Medical Problem – Wound
Create wound site, document wound education, & assessment findings
Click on Start New Wound Site &
complete pop-up box fields
Observation Precautions Tab
Observation Precautions Tab
1. Select reason patient is on Observation Precautions (suicide, violence, elopement, disorientation)
2. Select observation status (1:1, Eyesight, Q 15 minutes)
3. Monitoring
Current Workflow of
a. Patient location
hourly documentation of
b. Verbalizes Self Harm (yes or no)
observations on clipboard
c. Harmful Behaviors (yes or no)
d. Environment Check (yes or no)
will occur here HOURLY
Observation Precaution Hourly Workflow:
Documenting on multiple patients in one charting session
• To document on a series of patients:
1. Complete the documentation on patient #1
2. Save & Confirm
3. Go to top of HED screen to Patient Selection Drop
Down list & Click on Arrow
4. Select the next patient you want to document on
this opens this patient’s medical record
5. Click on the Observation Precaution Tab
6. Complete documentation on patient #2
7. Save & Confirm
8. Repeat steps #3 - #7
VPH Vitals I&O Tab
VPH Vitals I&O Tab:
Document Vital Signs, Height, Weight, Blood Sugars, & I&O’s in
this tab
Vitals are shared
result with
Protocols Tab
Height &
Weight
VPH Protocols Tab
RN: Protocols Tab
3 Protocol Types: CIWA, COWS, CNSDP
Drug & Alcohol
Withdraw Protocols
Symptom Scale Score:
1. Severity of symptoms & risk to
patient
2. Determines need for pharmacologic
intervention
Three Protocols:
1. CIWA – alcohol withdraw
2. COWS – opiate withdraw
3. CNSDP – benzodiazepine withdraw
RN: CIWA Protocol
(Score determines need for pharmacologic intervention. Add total score & enter.
Document dose #, cumulative dose, & drug name here & administration
documentation through Admin Rx)
RN: COWS Protocol
Add COWS score & enter total
Document which Drug is administered as per the Protocol
Document Cumulative Dose & Dose #
RN: CNSDP Protocol
Check for symptoms that are present, add #, document total score, then determine
need for pharmacological intervention per Protocol & document dose # & cumulative
dosage
Night Shift Documentation (11p-7a)
• Document sleep behaviors in the
Assessment/Intervention Tab (if MHS
documenting sleep will be documented in the
MHS Observation Tab)
• Document Observation Precautions – Hourly
• Document Pain Assessment
• Document any episodic events as indicated
• Document meds given in Admin Rx
• Other documented on “as needed” basis
VPH Education Tab
RN/MHS: VPH Education
1. Patient Orientation to Hospital – complete at time of admission
2. Patient Orientation to Unit – complete at time of admission
3. Education – other, discharge, symptom relief, safety
These fields are
addressed with
each education
episode
RN/MHS: VPH Group Education
1. Select Group Name
2. Challenges
3. Participation
4. Instruction Strategy
5. Progress toward Treatment Goals
Child & Adol Units
document in Peds
Group Section
StarPanel
VPH Nursing Admission History
VPH Episodic Event Note
VPH Treatment Review Committee Note
RN: Nursing Admission History
·Located in StarPanel
see Actions Menu or
Forms
·Demographic Data will
Auto-populate
· Some Data will
populates from
previous admits
·Document Pt Search
& Staff present
· Thorough Medical
History Review
· Create Problem List
· Save as Draft or Final
RN/MHS/SW: VPH Episodic Event Note
• This documentation format is
used for detailed narrative
descriptions of significant
episodes
• Episode examples include events
that led you to write a narrative
progress note in the paper
medical record
• Can be saved as a draft & later
completed
• Save as Final when completed
• Document can be viewed in
StarPanel All Documents (& soon
OPC)
Name, Age,
MR#, Gender
AutoPopulate
Hold Control key
to select more
than one option
Click here
to Save as
Final
OPC: To Review Nursing Data & MORE
• Central location for
Multidisciplinary Data
• RN mental status & risk
assessment data
• Vital signs, Withdrawal
Protocol data, Labs
• Hyperlinks to Progress
Notes, Consult Notes,
Nursing Episodic Event
Notes, & more
• Family Contact Info
• Current Order Sheet PLUS
electronic MAR
OPC: RN Assessment Data Displayed
Treatment
Review
Committee
•TRC Chair (Physician) is
required to complete the TRC
documentation
•TRC Attendance – requires two
MD’s, one staff member serving
as the Patient’s Advocate, &
two other clinical staff members
(RN, SW, Pharmacist)
•Documentation of patient’s or
family member’s presence is
required
•Patient name, age, MR#, and
gender will auto-populate
•Name fields have a “name
completer” functionality as you
enter the first letters of the last
name a list of employees will
open – select the right
individual
HED for Mental Health Specialists
MHS: Tab Documentation Overview
Charting Responsibilities for Assigned Patients – Where do I chart it??
• MHS Observations Tab: Mood, behaviors, interventions, risks,
ADL’s, food intake, sleep
• Observation Precautions Tab: HOURLY documentation for all
patients on 1:1, Eyesight, & Close Observation
• Vitals/I&O’s Tab: Vitals, weights, intake & output (if ordered) =
Vital/I&O’s Tab
• VPH Education Tab: Orientation to VPH & Unit when MHS
completes upon admission (telephone rules, visitation)
• VPH Education Tab: Group documentation
• Episodic Event Note: Narrative note on a patient event or episode
(i.e. outburst following phone call with family). In StarPanel
• Night Shift: Sleep Documentation within MHS Observation tab,
Observation Precautions, other documentation as needed
MHS Observation Tab:
1. Clinical Observations
2. Behavioral Interventions
3. Risk Observations
4. Nutrition Observations
5. Sleep Observations
6. Activities of Daily Living
Display PPT
Slide #3
MHS Observations Tab: Overview
Note some fields are labeled MHS (MHS to document), RN (RN to document or RN only field), or NO Job
Title (either can document – shared options in drop down)
Safety
Opportunity:
MHS can view displayed
RN Documentation for
General Behavior,
Hallucinations, & all Risk
Documentation Fields.
This provides both
information & a basis for
comparison.
MHS Observations
1. Document: See below for results to document
2. Demonstrate: Annotation, Save, Confirm, Change Time
3. Explain: Need to review RN documentation for Safety
Note: RN
Documentation
Each Field has a drop
down list, can select
more than one
descriptor, with
ability to annotate
comments
RN/MHS: Behavioral Intervention
1. Document: Select Intervention (“continue to monitor” should be routinely chosen
w/ other interventions added as indicated)
2. Document: Select patient’s response
RN/MHS: Risk Assessment Section
1. Explain: In this section, you will assess &
document clinical findings for:
1. Suicidal Behavior
2. Self Harmful Behavior
3. Violent Behavior
2. Safety Opportunity: Reinforce need to review
MHS’s clinical findings – pt may have shared
Suicidal thoughts with RN but NOT the
MHS!!!
MHS: Risk Observation
1. Document: Suicidal Ideation verbalized
2. Document: Plan – yes(annotate) Add Annotation (“Hang myself”)
3. Document: Interventions – Emotional Support, Environment Check, & RN Notified (
4. SSS Note: Emphasize importance of RN notification for patient safety – similar to critical vital
sign reading – BP = 230/120 or T = 104.6!)
Note the
RN’s
Findings
MHS: Risk Observation for Violence
1. Document: Risk for Violence = threatening. Explain: If Risk for Violence is identified,
Interventions must be activated & documented
2. Document: Interventions = Emotional Support, Environment Check, & RN Notified
MHS: Other Observation Fields
1. Document: Nutritional Observations
2. Document: Sleep Pattern & Intervention
3. Document: Activities of Daily Living
Enter % of
Food Intake
Select from drop
down for description
& Intervention
Next TAB!!!
Observation Precautions Tab
1. Document: Select reason patient is on Observation Precautions (suicide, violence, elopement,
disorientation)
2. Document: Select observation status (1:1, Eyesight, Q 15 minutes)
3. Document: Monitoring
a. Patient location
Current Workflow of
b. Verbalizes Self Harm (yes or no)
hourly documentation of
c. Harmful Behaviors (yes or no)
observations on clipboard
d. Environment Check (yes or no)
will occur here HOURLY
Demonstrate the ease of completing this
on 3 pts in a row - document, save,
select next pt from drop-down & repeat
Observation Precaution Hourly Workflow:
Documenting on multiple patients in one charting session
• To document on a series of patients:
1. Complete the documentation on patient #1
2. Save & Confirm
3. Go to top of HED screen to Patient Selection Drop
Down list & Click on Arrow
4. Select the next patient you want to document on
this opens this patient’s medical record
5. Click on the Observation Precaution Tab
6. Complete documentation on patient #2
7. Save & Confirm
8. Repeat steps #3 - #7
VPH Vitals I&O Tab:
1. Document: Vital Signs, Height, & Weight
Height &
Weight
Vitals are shared
result with
Protocols Tab
MHS/RN: VPH Education
1. Document: VPH Orientation to Hospital – If MHS completes this education at time
of admission, he/she should document
2. Document: VPH Unit Orientation – complete at time of admission
These fields are
addressed with
each education
episode
RN/MHS: VPH Group Education
1. Document:
- Select Group Name
- Challenges
- Participation
- Instruction Strategy
- Progress toward Treatment Goals (yes – will be most common answer in this field)
Child & Adol Units
document in Peds
Group Section
RN/MHS/SW: VPH Episodic Event Note
• This documentation format is
used for detailed narrative
descriptions of significant
episodes
• Episode examples include events
that led you to write a narrative
progress note in the paper
medical record
• Can be saved as a draft & later
completed
• Save as Final when completed
• Document can be viewed in
StarPanel All Documents (& soon
OPC)
Name, Age,
MR#, Gender
AutoPopulate
Hold Control key
to select more
than one option
Click here
to Save as
Final