Charting a New Course for
Patient Documentation
Super User Training
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What You Will Learn Today
Upon completion of training, the learner will demonstrate ability to:
1. Share the vision for the changes in nursing documentation
2. Identify at least 2 “Myths” that have been barriers to documentation
reduction in the past and verbalize an effective response to both
3. Complete a documentation scenario without assistance
4. Verbalize 3 expectations of a Super User during unit implementation
5. Identify 5 resources available to all staff to support transition to the new
documentation processes
6. Demonstrate 3 techniques most likely to be effective in promoting peer
adoption of the changes.
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THANK YOU
The Super user role is vital to3 implementation of this change!
Charting A New Course for Patient Documentation
Why chart a new course?
Nurses need more time with
their patients and to spend less
time writing about what they
are doing with their patients!
PUT VALUE BACK INTO WHAT NURSES DOCUMENT
With revisions, need to assure that everything that the nurse is documenting is valuable and
contributes to the patient story and informs
the care you and others give.
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FOCUS
Targeted design for the
proficient, ethical nurse
Not designed to be everything to
everyone
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STOP!!!
* Stop documenting MOST
normal values
* Stop charting data no one looks
at or uses
* Stop duplicate documentation
* Stop transcribing data from
devices
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Myth Busters
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“If it’s not charted, it’s not done.”
“I have to chart this because it’s required
by … “ [Joint Commission, Hospital Policy,
Risk Management, etc.]
“Quantity of documentation = quality of care I provide”
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We are reducing documentation in order to
increase nurse to patient ratios or make other
staffing changes.
NOT TRUE!
No further changes are planned to the staffing models.
Documentation reductions are needed to make the
model work better.
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Those making all these changes are out of
touch with what really happens at the bedsidethese changes will never work.
NOT TRUE!
Many levels of nursing were
involved in developing the
revisions.
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.
“Real Nurses” were involved
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What is NOT changing:
* Care Organizer & Admin-Rx
* General format of HED screens and way to
select items from drop down menus or
typing annotations
* Nursing Admission History still in StarPanel
* Clinical Care Classification (CCC)
standardized terminology for
documentation of problems
* Required documentation denoted by ALL
CAPS
* Concept of Priority Problems/ goals
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Patient Scenario
* Pt admitted with complaints of a deep and productive cough for 1 week
*
*
*
*
*
*
*
*
with progressively worsening yellow phlegm.
Wheezes present in BLL
Patient is asthmatic
Admission dx is pneumonia
Pt reports hx of asymptomatic AFib X 5 yrs
Patient small stage 1 PU on left buttock
Hypoactive BS
You receive the pt from the ED with antibiotics infusing in r forearm 20 G
PIV
Other than respiratory issues the patient healthy
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The Nit and the Grit of the changes
1. Sign on to CWS w/ your id
2. Click HED train icon
3. Use the training patient on your card
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New Tabs & Order
• In the training region you may see both
the current tabs & new tabs.
• In Live HED, the PLAN tab will load 1st
• Most of the new tabs are in ALL CAPS
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Old VS New Tabs
* Most of the new tabs will be in
ALL CAPS but there are some
existing tabs that are in ALL CAPS
too ( i.e. CRRT) that will continue
to be used as we transition.
* There are also some tabs that are
used now that will transition over
that are not in all caps – i.e. Blood
transfusion, chemo, Pain/CDR.
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* On the chart menu, there will also
be the tabs for the areas that are
not being implemented in this first
phase ( i.e. NICU, OB)
Pain Documentation
 In Live HED, you will see reduced fields for pain
documentation:
 Reassessment of pain is documented with a new score
 Pain documentation requirements have NOT changed,
there are just less fields to document on. Refer to Policy
Tech for more details.
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Pain Interventions
 Will not be found in the Assessment tab
 Can be found in Interventions, All Doc, Pain/CDR, or
AdminRx.
 New options:
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Learner Engagement
 In HED Live, you will see Learner Engagement
(session)
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Protocols Tab
 New Protocols Tab including CIWA, etc.
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Nursing Documentation Guidelines
Review
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Tips for ALL DOC
If you can’t find an item,
go to ALL DOC & use the
Add button to search
The following items can be found in ALL DOC:
• Transfer & transport
• Isolation Precautions (or in Interventions)
• Co-Sign (for students)
• Downtime
• Use the “Add” button to search for items
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Discharge
Discharge Plan of Care Reviewed, Discharge Readiness and Discharge Problems needing
follow-up have been moved from the Assessment/Problem section to the Plan of Care
section on the PLAN Tab & the Education tab.
A current shift assessment should
be completed prior to discharge,
problems needing follow-up should
be identified and documented with
a plan to address.
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When to Document What…
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Display of Data
Currently, most of the documentation is displayed in a real time view. Some spend a lot of time
adjusting times they document to be at the top of the hour so the data aligns in a single column,
making viewing info easier.
With the revisions, the displays of the data has been collapsed to facilitate easy viewing.
Data displays in 1 hour increments






VS/I&O
Assessment
Interventions
Pain/CDR
Device
Protocols
Displays in 12h increments


Plan
ALL DOCS
Displays in 24h increments

Education
Click Chart to see the actual Documentation Times
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Shift to Shift Handovers
Use the Plan tab to facilitate handovers. It should capture the patient story.
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Training and Implementation
Training
Manager presentation to
staff
For Super Users….
Attend SU class
Complete LMS
Complete unit based
practice scenario
Staff….
LMS
Complete Unit Practice. As
Super User f/u to see that
they have completed and
offer help with the unit
based practice scenario.
GO LIVE
Sept 15: Pilot 8N & 8S, VCH 8
Support
Oct 13: 5S, 6S, 7N, CTU, 7S
Oct 20: 10S, S34, S44, S64, S74, CRC
Oct 27: VCH
6th
&
7th
floors
1 Super User each shift on
each unit for the first week
Nov 3: 11N, 9N, 9S, 6N, 7S (?)
Nov 11: PICU, PCICU, 10N, 11S **NOTE
on Wed**
Nov 17: 8T3, 9T3, 10T3
Dec 1: S54, 5N CVICU, COBS, 6T3, 7T3
Dec 8: Adult ED, Peds ED
(Excluded: NICU/ Newborn
Nursery, VPH, ED, OB, Periop
and procedural areas & areas
that don’t document in HED)
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SSS 24X7 for 5 days
(covering multiple units)
Round and assist staff
**Review charting **
Trouble shoot
Transitioning from Old to New
GO LIVE DAY
 Tech team will push the new tabs to HED “LIVE”
by 0700
 Day shift will begin using the new tabs
 To view previous charting, toggle back to the
“old tabs” from the tabs drop down menu or via
the chart option in the top tool bar
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Role & Responsibility
Expectations of a Super User during unit implementation:
 At the Elbow Support to
Nursing Staff ( answering ?s and
coaching)
 Review Documentation via
chart audits and follow up with
users for any issues
 Report problems/Issues
 Roll model completion of ALL 4
LMS modules and Unit Practice
Scenario
 Follow-up with staff assigned to
you to encourage and track
completion of LMS modules and
Unit Practice
 Communicate to Manager any
concerns about readiness of staff
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assigned to you
Resources
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Resource
Resources available to all staff to support transition to the new
documentation processes
 Hover Overs/ Links in HED (Krames)/ Mosby
 Nursing Documentation Policy
 Job Aide
 Super User Guidelines for Nursing Documentation Support
 Systems Support Nursing Education Website
 FAQ
 Debriefing sessions
 Colleagues on the documentation committee/ SSS /Educators
 Help Desk
What Else???
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Online Resources
Click icon on desktop or link on
VUMC webpage
Type SSS in main VUMC webpage and
select System Support Services to get
our webpage.
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Promoting Adoption
Demonstrate 3 techniques most likely to be
effective in promoting peer adoption of the
changes.
 Timing
 Approach
 Follow-up
TAKE CARE OF THE PATIENT, then worry about charting!
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Timing Is Everything…
Would you approach a nurse or staff member in the
following situations?
 In the break room?
 At the accudose machine?
 Two nurses discussing the upcoming weekend?
 A care partner running with a crash cart?
 A nurse near a room with visibly
upset family?
 A nurse providing care?
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Approach
 Coach/ mentor – non punitive
 “ I am touching base with all RNs to see how
charting is going with the new system. It’s a big
change and I am here to help. What did you think?
Did you have any questions or concerns.
 Then give feedback… I noticed “…..”
 Do not give a huge list of issues- prioritize
 It will take a lot of coaching and practice
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Approach (cont.)
 More Direct Phrases to add to your collection
 “Can you tell me a time when I can come back?”
 Check with charge nurse for best times to return
considering typical unit workflow patterns
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Follow up
 Denote all ?s/Concerns and
seek out answers
 Prioritize
 Investigate
 Triage
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What’s wrong with this picture??
Admission Assessment
• Only chose 1-2 Priority
Problems
• Only set goals for those 1-2
priority problems
• Chart ALL categories on
admission
• Annotate WEL on admission
• Make sure there is
supporting data for OEL
• Is it WEL (baseline) or OEL?
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What about “difficult” users
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Strategies
 Don'ts
 Do’s
• Be comforting not confrontational.
• “I know it’s hard and it takes more time right now.”
• “I understand your frustration.”
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Role & Responsibility
Expectations of a Super User during unit implementation:
 At the Elbow Support to
Nursing Staff ( answering ?s and
coaching)
 Review Documentation via
chart audits and follow up with
users for any issues
 Report problems/Issues
 Roll model completion of ALL 4
LMS modules and Unit Practice
Scenario
 Follow-up with staff assigned to
you to encourage and track
completion of LMS modules and
Unit Practice
 Communicate to Manager any
concerns about readiness of staff
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assigned to you
Repeat after me….
SUPPORT CREDO
 I am responsible for getting this fixed, and for
documenting the problem and its solution.
 I understand that people are frustrated and angry,
but I won’t take their anger personally.
 I will empathize with the frustration that my peers
feel, and tell them that I understand and share their
feelings.
 I will calm them down with my words and manner.
 I will not accept abuse.
 I will not blame the user.
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Next Steps
Complete the LMS modules
Complete a Unit Practice ( on your own)
From your manager/educator, get list of staff you are
coaching (approx 10)
Communicate to SSS any concerns or questions
PLAY in HED train
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