Horizon Expert Documentation (HED) On-line Nursing Documentation

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Horizon Expert
Documentation (HED)
On-line Nursing Documentation
E-training for Medical Information Services –
Viewing & Printing HED Data from HED &
StarPanel
April, 2006
Using this tutorial
Information included on how to access and print
data charted by nurses in HED
•
•
HED Reports (available during the hospitalization)
In StarPanel Nursing Flowsheet (available in real
time during and following the admission) and
Reports (available post discharge)
Overview of HED
Nursing Documentation
• Nursing staff enter Vitals, I&O, Assessments,
Interventions & Admission History data in HED
• Data from monitors (now) and Vents (soon) downloaded
into HED (nurse acceptance required)
• Data saved to StarPanel in real time. Copies of
completed documentation sent to StarPanel after
discharge.
• Others access data from HED (review screens or
reports) or StarPanel (flowsheet or PDF of HED
documents)
• Medication administration still documented on paper
MAR. Most patient teaching on paper Teaching Records.
Some specialty forms still on paper.
1. Viewing HED data in StarPanel Nursing Flowsheet
Nursing Flowsheet
From Patient View or
Panel, click on “Action”
& select Nursing Flowsheet
*** Note -- other similar flowsheets will probably be added over time.
From within an individual
patient’s record, select
Flows option and Nursing
Flowsheet
Continuous is
default frequency
for data display.
Click on Q4hrs or
Q2hrs for more
dense display
Flowsheet will
display in the
Red frame
A small yellow box outlined in red is
similar to a Post-it-Note. To see the
annotation, hover over the box with your
mouse and the note’s contents will appear
to read.
Entries in red are lab results outside the “normal’ range OR are entries flagged by the person who made the entry that
are significant. For example, if pt. has an order to notify HO for temp > 101.5 and the temp is 102, the nurse should
mark it as being significant so it will appear with a red colored font.
Default is to display
only up to 48 hrs.
data. Click to display
all available data.
Click on check mark to
compress section. Section
will display as single gray
column. Click to re-expand.
Other hyperlinks to allow
more convenient navigation
Beige background indicates
that there is either a comment
or more than one value
associated with the space.
Hover over or click on the
section to display.
2-A. Changing Preferences so you can view/print
HED reports in StarPanel
Click on Customize from Side Bar
Click on Preferences
NEW
Before you can see the HED Reports in StarPanel,
you must first change your “Preferences” as these
no longer display by default without this change to
your settings.
Change to
Yes
Default setting is No
ALL View with HED PDF Reports Displayed
48 Hours post
discharge, HED
Reports will display
in the All List.
Blue shaded area
denotes
hospitalization
If you do not change Preferences,
these will NOT display
2-B. Viewing/Printing PDFs of HED
data from StarPanel.
Documents and results associated with ED
and Inpt. Episodes of care have a light blue
side bar by all of the dates of that encounter
HED reports are sent to StarPanel approx. 48
hrs. post discharge (the point at which the
record can no longer be altered) so look
above the blue bar to see HED reports.
Click on the diamond by each document to be
viewed/printed. Once selected, the diamond turns red.
Under Actions, click on Show to display
selected documents in frame below
Report Name
and date
generated
Confirms this
is an HED
report
Click on Hyperlink
to display report in
next frame
An Adobe Acrobat
window opens to
display the report in a
new window
Header information
Click print icon
to print
“&” denotes that a comment
was entered
Comments text, date/time entered, ID of the person who made the entry, are displayed at the bottom of the
section right before the next section. (Eg. Bottom of the Neuro Assessment and right before Cariology
More examples of
Comments displayed
At end of each section
To view the next document, in Action box,
click on Show. The report will display in the
next bx.
Modification/Inactivation Report shows all
alterations to documentation in HED.
3. Viewing/printing HED from within HED
2. Select new Patient from Census:
• From Dept. drop down list, select patient’s unit
• Highlight patient name and click OK button.
7N
To access data
directly from HED:
1. Click HED icon
Do you have HED access?
If you have Wiz Order access, you should
have HED access but we sometimes need
to intervene to provide proper access. If
you need assistance, contact the Help Desk.
If you don’t have Wiz or HED access, your
Security Admin will need to request for you.
D OE, JOHN
7N
7024
1
VUM
Sample review screen. Click on “Views” to
see other flowsheets. Click on “Configure” to change
the way information is displayed in the review
and to see cumulative I&O totals
Change to 30 days to
see data more than 72
hrs. old
Click on “12 Hour” to display cumulative
I&O shift totals.
Click on “24 Hour” to display cumulative
24 hour I&O totals.
Click on ‘Shift” to display 8 hr. shift
Totals and running cumulative totals.
To open Admission History, click on tab.
[Note: separate Admission Histories for
Peds and Subacute.]
1. Aqua blue shows items that have been
completed on Admission History.
2. Gray items negative or not completed.
3. Click on item to open
that section to view or
document.
4. It will open up a data
entry screen like this.
Note: Longitudinal data (Medications, Allergies, Problems) can be view like this at any time.
Once accepted, episodic data can be viewed ONLY from Reports or Review screens.
To print Admission History:
1. Click on Report tab.
2. Select Admissioin History Part 1 &
Admission History Part 2 Ext. data
[Separate reports for Subacute and Peds
Admission Histories]
To print reports, click
“Send” and then
“Return”
Names of all Reports that
Can be printed from within
HED at present. (Some have
Not been customized for VUMC
Yet).
Episodic data as
seen on the
Admission History
Review.
Click on a cryptic
abbreviation and a pop
up window with a
complete word will
appear.
Summary – ways to
access data
• Flowsheet in StarPanel is used by physicians
and ancillaries to view data charted in HED
(permanent).
• Views and reports also available in HED while
the patient is admitted.
• 48 hrs. post discharge, PDF versions of all HED
data sent to StarPanel. Can be viewed and
printed from there but to see these, you must
change your preferences so they are unhidden.
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