Education Tab
Safety/Falls Risk under Peds Assess/Intervention
The Education Record Tab now follows the Priority Problems format.
Identify who received your teaching as
well as other pertinent information. If
necessary, use the post-it note to
annotate additional comments as usual.
3
Start With the Education Record Tab First
Upon admission, identify the appropriate Care Contacts for your patient.
This information needs only to be entered once during the admission
(unless there is a change).
The hover-over feature gives a
precise description of the expected
documentation to that area.
4

Safety assessment on every patient, every shift.

Falls Screen
o
o
Adults: Morse Falls screen
Peds: Humpty Dumpty Falls
o
o

Streamlined documentation of Restraint Safety Care
Safety Problems (Injury Risk, Violence Risk, Substance Abuse, and
others) will be identified.
o
o

on admission, q shift, and with condition changes
If a safety problem will be a key driver of nursing care for that patient,
also initiate as a Priority Problem
CIWA documentation will be available in HED for units that implement
CIWA protocol
Safety Interventions will be documented – things you:
o
o
o
o
Assess/Monitor/Evaluate/Observe
Care/Perform/Provide/Assist
Teach/Educate/Instruct/Supervise
Manage/Refer/Contact/Notify
Peds Falls Assessment Score Auto-Calculates
 Peds Falls assessment
score will be auto
calculated
 Continue to chart Falls
Risk Assessment
Interventions for Standard
or High Risk
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The Safety Risk Assessment and appropriate documentation need to
be done every shift and PRN.
 Only need to document against applicable fields
 You can start a Priority Problem from here, if applicable. Now
only need a Priority Problem if the safety issue is driving care or
restraints in use
 Document Response to Safety Interventions in Nursing
Summary and Plan Priorities at end of shift
10
NEW Safety/Fall Risk Documentation
Below Peds Falls Assessment, the
new Safety Risk Assessment will
display to incorporate everything
related to Safety:
 Peds Falls assessment will be
auto calculated
 Falls Risk Assessment included
 NEW Safety Assessment to be
completed qshift
 Safety Monitoring
 Safety Care Implemented
 Safety Education/Engagement
 Safety Notification/Care
Coordination
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Contributors
to fall or
injury risks
Interventions
for falls risk
patients
Interventions for
violence/injury
Restraint documentation, located within Section 2 is streamlined:
 Document the “Restraint Status”
 Checking “done” to “Restraint Safety and Comfort Care” reflects that
you have done all the descriptors seen when using the hovering
feature
 Document against both of these fields Q2H
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




1. All patients are on Standard Falls Precautions_____
2. Falls risk assessment is done on admission and at
discharge_____
3. You will now be able to chart falls events on the
falls/safety tab____
4. For high risk falls patients, interventions could
include: ambulating with the patient, monitoring
medication side effects, keeping the room cleared,
having the patient to wear yellow socks and yellow
armband, and placing LAMP sign on the patient’s door
______
5. You can only start a safety/fall priority problem on
the poc tab_____
6. Safety assessments are done q day_____