Charting a New Course for Nursing Documentation
Oct. 26, 2015 Update
Rollout Schedule:
Peds Acute Care Units – 6th and 7th floors, VCH (10-27-15 go live)
Adult Acute Care Units Group 3 – 9N, 9S, 6N, 11N (11-3-15 go live)
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:
Mental Status Assessment
Documentation of Mental Status is required for all patients as part of initial Neuro Assessment each shift. Based
on extensive VUMC evaluation and use – RASS, although not perfect, is a simple, reliable indicator that can
capture cross venue changes in patient mental state. The new Nursing Documentation policy that is currently in
draft form does include this element as required and it does display in ALL UPPER CASE as a visual cue to chart at
least once per shift. Hover over the words to see brief directions on completing a RASS evaluation.
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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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Issues that will be addressed with the HED Push Tue. morning 10-27-15
Issue
Response
Need ability to document % food intake on some
Modified version of this field is back. Should be
patients
documented on patients with actual or risk for nutrition
problems and as ordered.
As previously mentioned, many questions about RASS. “RASS” is now “MENTAL STATUS/RASS” on tabs where it
can be charted.
Need faster way to document a few items that are
With input from both ICU and Acute Care Nurses, we now
assessed very frequently.
have a new Frequent Assessment section on the Vitals/I&O
Tab – right below ED Comments.
FLACC missing from Pain Scale drop down
It’s back!
Breast feeding options were missing from Care Assist 2 These elements are now available.
Tab.
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