
Changing focus from repetitive screening for Falls Risk to a model that
supports Falls Prevention

Historically for each new issue addressed, we’ve added a new section or
Tab to HED – not sustainable and adds complexity to documentation

Framework developed to identify and address all safety risks efficiently

Pilot focuses on:
◦ Falls Risk portion of new Safety Build
 Other New features that will be addressed:
◦ Role/Communication documentation
◦ Changes in documentation of Patient/Family education &
engagement
◦ Changes in Restraint, CIWA, and some other safety-related
documentation
RNs complete hands-on check off on documentation and workflow
associated with new Falls/Safety HED build

Practice Scenario:
o
Determine the Morse Falls Risk Score
o
Identify safety risk factors and safety problems ; Start Safety or Restraints Priority
Problem, if warranted
o
Document, Care Interventions, Patient/Family Teaching, and any Notifications &
Care Coordination
o
Document shift goals/outcomes for Safety Priority Problems & response to safety
interventions
Safety Risk Assessment
Safety Plan
Response to Interventions
1. Assess
2. Care
3. Educate
4. Notify
 Role Communication Section
(caregiver contact info)- nurses to
document caregivers contact info
once and if any phone number
changes
 Education Categories – categorized
in similar fashion to Priority Problems

Safety assessment on every patient every shift. Also
o 9N: Morse Falls screen on admission & with change in
status/condition (e.g. Transfer to different level of care, change in
mental status, etc.)
o 6A/B: PEWS screen documented q4h (will be moved from
Falls/Safety Tab at conclusion of pilot before VCH-wide rollout)

Safety Problems (Injury Risk, Violence Risk, Substance
Abuse, and others ) will be identified.
o If they are a priority, also initiate this as a Priority Problem

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
New Education Tab:

Caregivers’ contact information (“Care Contacts”) – will be documented
in new Role/Communication section

Patient/Family Education & Engagement

Some other Safety documentation (eg. Restraints) streamlined.

Plan of Care documentation
 Priority Problems – continue to create and evaluate goals
 Pathway, Nursing Summary, and Plan Priorities documentation in HED
 Continue to assign e-docs pathway
 Education Record tab still visible for pilot until further discussion as to whether to blend the
new Education tab with current one

Admission History documentation of substance screening and caregiver contact
information will still be recorded until further evaluation with pilot
Admission
• Morse Falls Risk screen
• Safety assessment as part of head-to-toe assessment; Identify problems
& Plan Interventions; Start Priority Problem if warranted
• Safety assessment; Identify problems & Plan Interventions
Beginning
of Shift
• Document expected Short Term Goals for Safety Priority Problems
• Start/End Safety Priority Problems if warranted
• Document Short Term Goal Status or outcome for Priority Problems
End of Shift • Document Response to all Safety Interventions
Condition/
Status
Change
• Morse Falls Risk screen
• Repeat other Safety Assessment & Revise Planned Interventions as
appropriate
Admission
• Morse Falls Risk screen
• Safety assessment as part of head-to-toe assessment; Identify problems
& Plan Interventions; Start Priority Problem if warranted

Click on HED Train tab and select the Safety Falls/
Risk tab

Locate and complete the Morse Falls Risk Section
– bottom of screen

Complete Safety Risk Assessment
Admission

• Morse Falls Risk screen
• Safety assessment as part of head-to-toe assessment; Identify problems
& Plan Interventions; Start Priority Problem if warranted
How would you assess the patient’s:
◦ Ambulation aid
◦ Gait
Hover over boxes with HED Upgrade on many
fields
• Start/End Safety Priority Problems if warranted
• Document Short Term Goal Status or outcome for Priority Problems
End of Shift • Document Response to all Safety Interventions

Continue to document:
◦ Nursing Summary, Plan Priorities, and Goal Status

Include from Safety/Falls tab end of shift
documentation on:
◦ Response to Safety Interventions
Condition/
Status
Change

• Morse Falls Risk screen
• Repeat other Safety Assessment & Revise Planned Interventions as
appropriate
Re-Assessment of Morse Falls Risk Screen and
Safety Assessment with:
◦ Change in level of care (unit-to-unit)
◦ Status Change
◦ Fall or injury
◦ Increased monitoring of patient’s condition due to status
change
Day of
go-live
also

New Safety/Fall Risk tab will replace the old Falls Risk section in
assessment tabs

New Education tab will appear- old Education Record tab will still be visible

Restraints documentation moved from Restraints tab to Safety/Fall Risk tab

Past data will be viewable for the Restraints tab, and Fall Risk section but
will not contain charting boxes.

CIWA tab released

Resources:
◦Super Users – in-staffing
◦Educator
◦Unit Resource Manual- contains issue
log, pocket aides, staff& support
schedule, and pocket aides
Implementation
Support
◦ SuperUsers
◦ SSS/CAPS: 9a-5pm and 9pm to 5am, Sept. 18, 19, 20, 21st
◦ Issues Log on unit