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 reassessments 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
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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, patientfocused 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.
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 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
- PAIN
- NEURO
- CARDIAC
- Vascular/Perfusion
- RESPIRATORY
- GASTROINTESTINAL
- SAFETY/FALL RISK
- SKIN/WOUND
- URINARY/RENAL
- Activity/Musculoskeletal
- Fluid/Nutrition
- Medication
- Infectious/Metabolic
- Psychosocial
- Reproductive
- Self-care (ADL)
ADM
X
X
X
X
X
X
X
X
X
X
X
X
X
X
OB
X
QSHIFT +
X
X
X
X
X
X
X
X
FOCUSED
REASSESSMENT
if problem/risk
if problem/risk
if problem/risk
if problem/risk
if problem/risk
if problem/risk
if problem/risk
if problem/risk
if problem/risk
if problem/risk
if problem/risk
if problem/risk
if problem/risk
if problem/risk
if problem/risk
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
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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.
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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
Monitoring
Direct Care
Direct care
Direct care
Direct care
Education
Communication
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Intervention
Vital Signs
Trach care
Med administration
Pressure ulcer prevention
Seizure precautions
Pacemaker education
Notify HO if temp >
Document
Real-time
Q Shift
Real-time
Near-time
Near-time
Q Shift
Near-time
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Guideline (if not prescribed)
Mosby Skill
Mosby Skill
CL 30-06.01
CL 30-09.01
Mosby Skill
Krames – Adult
-
Monitoring & Direct Care
Monitoring 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 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 tab
The 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
PLAN
VS/IO+
PARTNER
ASSESS
- PAIN
- NEURO
- CARDIAC
- Vascular/Perfusion
- RESPIRATORY
- GASTROINTESTINAL
- SAFETY/FALL RISK
- SKIN/WOUND
- URINARY/RENAL
- Activity/Musculoskeletal
- Fluid/Nutrition
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INTERVE
ADMINRX
PAIN/CDR
TEACH
DEVICE
ALL
DOC-
APH
ASS
DIA
ECM
POC
TRA
ETC
- Medication
- Infectious/Metabolic
- Psychosocial
- Reproductive
- Self-care (ADL)
- PAIN
Seq
TAB – NAME
PLAN
1
2
VS/IO+
VS/IO_4h
3
4
5
PARTNER
ASSESS1
ASSESS4
INTERVENTION
6
ADMINRX
7
8
PAIN/CDR
EDUCATION
9
DEVICE
9
A/D/T
10
ALL DOC-
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PROTOCOL
ALPHA SORT
APHERESIS
ASSIGN
DIALYSIS
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view
12h
FULL NAME/ PURPOSE
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.
1h,
VITAL SIGNS_INTAKE & OUTPUT + MONITORED DATA (DAS),
4h
PEWS, MEWS (future)
+ INTERVENTIONS?
4h
CARE PARTNER – One tab for all data entry by care partners
1h,4h ASSESSMENTS/PROBLEMS - Less scrolling with interventions
removed
1h
INTERVENTIONS/PROCEDURES - includes complex procedure w/
significant charting that also have its own tab (ECMO, CRRT…)
1h
MEDICATIONS - Medications, immunizations… Related drug
teaching
1h
PAIN + CONTROLLED DRUG RECORD
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.
1h
COMPLEX MECHANICAL DEVICE requiring extensive
documentation
Ie IABP, CRRT, DIALYSIS
24h
ADMISSION/DISCHARGE/TRANSFER
Establishes baseline. Contains all the elements required on
admission, internal transfer, and/or discharge to home or other
facility. Includes post-mortem data
12h
ALL DOCUMENTATION – Assessments, Interventions, Education,
Plan
1h
RISK SCORING – Infrequently done risk scoring whose many
elements fall across care categories. - NAS, WATS, CIWA, PEWS,
MEWS?
1h
1h
APHERESIS
PATIENT ASSIGNMENT
HEMODIALYSIS & PERITONEAL DIALYSIS
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ECMO/CRRT
1h
ECMO, CRRT
POCT
4h
POINT OF CARE TESTING
TRANSFUSE
15m BLOOD & BLOOD PRODUCT TRANSFUSION
ETC
ETC
View is the default timescale with which to view trended data.
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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
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LEARNER(S)
EXAMPLE
PREFERRED LANGUAGE
Preferred learning mode
Interpreter Name or ID#
Care Contact 1 Name1
Care Contact 1 Role
Care Contact 1 Language
Care Contact 1 tel #
Care Contact 2 Name2…etc
EDUCATION & ENGAGEMENT
Discharge Plan Reviewed
DISCHARGE READINESS
Knowledge Deficit
Education/Engagement goal
Spanish
Video
87657
Anna Perez
Spouse
English
615-222-1234
Learner engagement (session)
Education comments:
EDUCATION
Handout(s) (annotate)*
Hospital Orientation
Medication education
Nutrition/Fluid education\
Pain Mgmt education
Safety education
CC1 Tbk, video
Skin care education
Tobacco cessation education
DX/PROC**
Cardiac education
GI education
Infectious disease education
Mental Health education
Nephrology education
Neuro education
OB/GYN education
Oncology education
Orthopedic education
 done
Knowledge deficit
Medication
understands drug precautions
HF bifold

Anticoaguants: Warfarin
Low Na diet, 1000ml fluid
Developer guideline
Goals match knowledge,
skill and adherence
problems
AHFS Classes
CPR, EMS

Krames folder structure
Heart Failure, BP Control
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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”.
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Pulmonary education
STD education
Surgery – General education
Urology education
Vascular education
Exhibit _ Admission History
Exhibit - Admission History
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Exhibit _ Protocol Tab
The 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 SIGNS
BLOOD PRESSURE
HEART RATE
PAIN SCORE
RASS
RESPIRATIONS
TEMPERATURE
- CIWA - ALCOHOL WITHDRAWL
auto
CIWA Score (auto-calc)
CIWA: Temperature
CIWA: Pulse
CIWA: Diastolic BP
CIWA: Respirations
CIWA: Nausea/vomiting
CIWA: Tremors
CIWA: Anxiety
CIWA: Agitation
CIWA: Sweats
CIWA: Orientation
CIWA: Tactile
Disturbances
CIWA: Auditory
Disturbances
CIWA: Visual
disturbances
CIWA: Headache
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[Hover text]
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 >
0= Less than 98.7 1= 98.7 – 99.5 2= 99.6 – 100.4 3= greater than 100.4
0= Less than 90 1= 90-95 2= 96-100 3= 101-105 4= 106-110 5= 111-120 6= greater than 120
0= Less than 95 1= 95-103 4= 104-112 6= greater than 112
0= Less than 20 1= 20 – 24 2= greater than 24
Ask 'Do you feel sick to your stomach? Have you vomited?'
Arms extended and fingers spread apart
Ask, 'Do you feel nervous?'
Observed
Observed
Ask 'What day is this? Where are you? Who am I?
Ask, 'Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs
crawling on or under your skin?'
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?'
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?'
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
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- MEWS – Early Warning
Score
value
Drop down single select list or hover
MEWS Score (auto-calc)
auto
MEWS: Respiratory Rate
2
0
1
2
3
MEWS: Heart Rate
2
1
0
1
2
3
MEWS: Systolic BP
3
2
1
0
2
MEWS: Urine output
3
2
1
0
MEWS: Temp
2
1
0
1
2
MEWS: Conscious level
3
2
1
0
Notify MD if >3 - 4 or greater will turn red. Source:
http://www.ihi.org/resources/Pages/ImprovementStories/EarlyWarningSystemsScorecardsThatSaveLives.a
spx
 <8
 9-14
 15-20
 21-29
 >29
 <40
 40-50
 51-100
 101-110
 111-129
 >129
 <70
 71-80
 81-100
 101-199
 >200
 < 10 ml/hr
 <30 ml/hr
 <45 ml/hr
 >45 ml/hr
 <35C or ?F
 35.1-36C
 36.1-38C
 38.1-38.5C
 38.6 C
 Unresponsive
 Responds to pain only
 Responds to voice or New agitation/Confusion
 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.
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A
B
C
D
E
F
CCC Care Categories & Definitions
Admission History
Nursing Documentation needed for Clinical Decision Support
Nursing Documentation needed for Regulatory Requirements
Documentation frequency
Protocol: CIWA
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