Last Updated August 2013

FLOWSHEETS:
 NICU VITALS
 ALL VITALS SIGNS ARE DOCUMENTED HERE
 NICU ASSESSMENT
 THIS IS WHERE YOUR QSHIFT HEAD TO TOE
ASSESSMENT IS DOCUMENTED AND MOST
NON – IV LDAs ARE ADDED FOR ASSESSMENT.
 IV ASSESSMENT
 THIS IS WHERE ALL PIVs AND CVCs ARE
DOCUMENTED.
 NICU I & O
 DOCUMENTATION OF ALL VOLUMES IN AND
OUT ARE DOCUMENTED. ALSO DOCUMENT
UNMEASURED URINE, STOOL AND EMESIS
HERE AS THE NUMBER OF OCCURRENCES.
 NICU DAILY CARES/SAFETY
 DOCUMENTATION OF SHIFT CHANGE SAFETY
CHECKS, APNEA AND BRADYCARDIA, AND
ALL OTHER DOCUMENTATION THAT IS
REQUIRED EVERY SHIFT.


For a list of required documentation, from the
Patient Lists screen, click on the patient once.
Type req doc in box next to spyglass. Choose IP
required documentation from the list.
Every shift:








Daily Assessment
Newborn Safety
Hard of Hearing Assessment
Education Documented
NSRAS (Once per shift)
NSCS (every hands on)
Pain assessment (every hands on)
Admission:






Vitals, Weight
Careplan added
Pain Assessment
Head to Toe Assessment
NSCS
Hard of Hearing Assessment (w/in 2 hours of
admission)
On admission complete the top box of the paper
Communication Request Form. This replaces
the Special Needs form that we used to use. We
have these forms in English and Spanish. Make
sure the parent(s) sign it.
 If there are special needs identified, complete
the rest of the form.
 The secretaries will scan the form into the
electronic chart when it is completed.
 Nurses complete the admission HOH
documentation in EPIC








Go to Patient Station
Click on recent patients
Double Click on name of patient
Click on Event Management
Click on Update
Click on Encounter Info
Click on HOH and answer question from dropdown
menu.
Every shift, the nurse will document in EPIC
under the shift assessment, “Deaf/HOH” task,
answering the first and third questions:
“Companion Deaf or HOH?” since parents are
companions in our NICU environment.
 Nurses do not have to ask this question of
parents every shift – simply assess while you are
updating them whether they can communicate
with you or not, and then document based on
that finding.


To add an LDA:
 Add all LDAs to assessment flowsheets, either NICU assessment
or IV assessment.
 Search under NICU first to find the LDAs built specifically for us.
To document the insertion: Go to Doc Flowsheet, then click on 'IV
Assessment'. Click on 'Add LDA' Then type in "NICU" to see all of the NICU
line options. Once you select the appropriate line, the insertion
information box will open up. Please be as complete as possible. For
PICCs, be sure to document the cut length, the cm mark at the skin and
the amount of catheter that is "exposed". All of those lengths are counted
from the most distal black dot.
* if you do not choose a NICU LDA, then the correct lines for ongoing
documentation will not populate on your flowsheet.
 FYI, the soap for staff use that is stocked in the NICU is Chlorhexidine. We
currently use the Biopatch (Antimicrobial patch) for infants > 60 days of
age (the 2 kg thing is for PICU).


It is not necessary to document the cm marking in the flow sheet portion at
the time of insertion since this gets documented and tracked through the
placement information. It is, however, imperative to document all line
adjustments in the flow sheet to prevent inadvertently malpositioned
catheters.

For Line adjustments, the person making the adjustment, the cm pulled
back, the cm mark at the skin/umbilicus and the cm exposed (if a PICC)
must be documented. click on "file" in the top left corner to put this
information in the "last filed" column so it can be readily seen by everyone.

For line removals : Click on the blue highlighted line insertion information
then click on 'Edit‘ Click on the reason for removal (please be specific) and
the catheter length upon removal, etc.
For short, scheduled downtimes, simply avoid order entry or documentation
during those few hours if you can. If downtime continues across change of
shift or lasts >4 hours, utilize all the information below.


RN Responsibilities
Before downtime:


***ADMINISTER AND DOCUMENT ALL DUE
MEDICATIONS IN EPIC PRIOR TO SCHEDULED
DOWNTIME.
During downtime:
CHART ALL VITAL SIGNS, INTAKE AND OUTPUT AND
ASSESSMENT DATA ON PAPER FLOWSHEET.
 CHART MEDICATIONS ON PRINTED MAR. ONCE THE
MAR DOSES ARE COMPLETED OR IN ORDER TO
CHART MEDICATIONS ORDERED DURING THE
DOWNTIME , USE THE DOWNTIME MEDICATION
RECORD.
 ALL FORMS WILL BE STORED IN THE SHADOW
CHART AND THE SHADOW CHART WILL BE KEPT AT
THE BEDSIDE UNTIL THE DOWNTIME IS COMPLETE.


After downtime:
RNs ENTER ALL DOWNTIME VITAL SIGNS, INTAKE
AND OUTPUT, NEW LDAs, AND ANY ASSESSMENT
CHANGES IN EPIC FROM THE PAPER FLOWSHEET.
 LINK ALL MEDICATIONS TO LDAs AS APPROPRIATE.
 DOCUMENT DOWNTIME DURATION IN EPIC
PROGRESS NOTE: “EMR DOWN x/x/xx 2300 UNTIL
x/x/xx 0400. SEE PAPER CHART FOR ADDITIONAL
INFORMATION”

Unit secretaries responsibilities
 Before downtime:


LOG ON TO THE BCA COMPUTER TO ENSURE YOU HAVE ACCESS.
CHECK DOWNTIME BOXES FOR:











ADD UNIT NAME, FAX NUMBER, AND UNIT PHONE NUMBER TO ALL
REQUISITIONS.
PRINT 3 COPIES OF THE UNIT CENSUS (ONE FOR CHARGE NURSE,
ONE FOR UNIT SECRETARY AND ONE FOR CENSUS RECONCILIATION
AND EVENT FORM TRACKING – THIS WILL BE DONE BY UNIT
SECRETARY).
PRINT EXTRA SHEETS OF LABELS FOR EACH PATIENT
FROM BCA COMPUTER, PRINT MAR FOR EACH PATIENT ON THE
UNIT AT 2100 ON THURSDAY.
LABEL EACH PAGE OF A FLOWSHEET FOR EACH PATIENT IN THE
NICU.
During downtime:




DOWNTIME MAR – ONE (1) PER PATIENT
NICU FLOWSHEET – ONE (1) PER PATIENT
BLANK PHYSICIAN ORDER SHEETS
DOWNTIME LAB REQUISITIONS
DOWNTIME RADIOLOGY REQUISITIONS
SECRETARIES PRINT ORDERSETS AS NEEDED FROM THE BCA
COMPUTER. DON’T FORGET TO LABEL EACH SHEET.
COMPLETE ADT EVENT FORM FOR EVERY NEW ADMISSION,
TRANSFER, OR BED MOVEMENT AND FAX TO REGISTRATION AT
2628.
RECORD NUMBER ON TOP LEFT OF ADT EVENT FORM ONTO THE
TRACKING COPY OF THE CENSUS.
After downtime:


Enter all orders (except stats and medications) received during
downtime in epic.
Scan all MARs, blood administration, vital signs, flowsheets,
consents, hoh assessments and other critical forms to medical
records at 703-889-2127.
MD/NNP responsibilities
 During downtime:





SECRETARIES PRINT ORDERSETS AS
NEEDED FROM THE BCA COMPUTER.
DON’T FORGET TO LABEL EACH SHEET.
Although we have a printer associated
to the BCA computer, it rarely works.
Instead, switch the printer to HP
Laserjet 4050 Series PS.
BLANK ORDER SHEETS CAN ALSO BE
USED FOR INDIVIDUAL ORDERS. DON’T
FORGET PATIENT LABELS.
PHYSICIANS/NNPs MUST INCLUDE DATE,
TIME, SIGNATURE AND PHYSICIAN
NUMBER WITH EACH ORDER!
LIMIT NEW ORDERS OR
MODIFICATIONS OF ORDERS TO
EMERGENCY USE ONLY!
Charge nurse responsibilities:
 Before downtime:


Make sure unit secretary has all
preparations in place for downtime.
During downtime:
LOG ON TO THE BCA COMPUTER TO ENSURE
YOU HAVE ACCESS. PRINT MARs FOR EACH
PATIENT IN THE NICU.
 SCAN EACH ADMISSION’S HEIGHT, WEIGHT
AND ALLERGIES ON A BLANK ORDER SHEET
TO PHARMACY VIA PYXIS CONNECT
(PHARMACY SCANNER).
 COMPLETE ADT FORM FOR EACH NEW
ADMISSION AND FAX TO REGISTRATION.
 SCAN EACH NEW MEDICATION ORDER TO
PHARMACY VIA PYXIS CONNECT


After downtime:
CHARGE NURSE WILL COLLECT DATA ON
RECOVERY PROCESS USING SUPPLIED DATA
COLLECTION TOOL.
 If you have tried everything and don’t know
how to do something, call the customer
support line.
 If they can’t help, call Ilona 






BARCODE SCANNING SHOULD BE USED AT ALL
TIMES.
CLICK ON THE BLACK TIME IN THE
MEDICATION ROW TO BEGIN THE
DOCUMENTATION PROCESS.
LINK MEDICATIONS TO THE IV LINES WHERE
THEY ARE ADMINISTERED.
BARCODES ARE A SAFETY CHECK FOR
MEDICATION ADMINISTRATION. IF UNABLE TO
SCAN THE BARCODE ON THE MEDICATION,
SEND A MESSAGE TO PHARMACY.
TO FINISH AN IV FLUID, MAKE SURE YOU
CHART STOPPED IN THE RATE ROW (USE THE
SYRINGE) AND THEN CHART A ZERO IN THE
VOLUME ROW. THIS INCLUDES IV INFUSIONS
AND INTERMITTENT MEDICATION INFUSIONS.
 Transfusions:






You must utilize carefusion for all
transfusions unless it is an emergency.
Remember to complete the transfusion
in carefusion when it is done; otherwise
the documentation will never show up
in EPIC.
To find the documentation in EPIC, click
on Chart Summary -> Media Tab ->
Transfusion Record
Once the transfusion is complete,
please shred the paper record. Do not
put it in the shadow chart.
If documentation was done on the
paper record, please scan to medical
records and keep this in the shadow
chart once completed.
To add vital signs during the
transfusion, use the tranfusion activities
hyperlink and then the vitals button.

Physician places order for discharge and completes
medication reconciliation. Then the nurse can
complete her portion for discharge:

Click Newborn Navigator, then Discharge tab

Click on Running Infusions to ensure that any IV
fluids have been discontinued.

Click LDA Removal and discontinue any remaining
lines, drains, or airways.

Click Patient Education and resolve education plan.

Click Care Plans and complete any open care plans

Click Preview AVS, print three copies and have the
parents sign one copy. Two copies to parents (one for
their files and one for them to take to the
pediatrician). Remaining signed copy is placed in
black chart. Also do the same for the physician’s
discharge summary printing three copies as above.

Click Discharge Note and write note.

Call Charge nurse and Secretary when infant
discharged and take black chart to front desk.
Use Discharge Navigator
 In some cases, you will still have
running infusions and active LDAs
 Verify that the physician has
completed Medication
Reconciliation and Added a
Discharge Order.
 You do not need to print the AVS
unless there are appointments for
follow up listed there.
 Update Careplans and Patient
Education.
 Once patient has left the unit, ask
the unit secretary to discharge
patient from the unit in EPIC.
 Copy chart (call medical records)

 Use
the Transfer Navigator
 Check under transfer status to
see if the transfer order has
been written
 Follow the Navigator
sequentially, verifying LDAs,
writing a Transfer Note,
updating Careplans, and Patient
Education.
 Use iSHAPED tool to give report
to receiving nurse.
Use
the discharge
navigator as with any
discharge following the
steps as outlined.
Print the AVS for the
receiving hospital.
Send the shadow chart to
medical records to be
scanned into the medical
record.
Admission and discharge summary.
 Maternal record (Delivery
Summary).
 Med reconciliation.
 Last few day's progress notes.
 Reports on selected imaging studies
(MRI, ECHO, EKG, holster, CT,
ultrasound) & the most recent Xrays (Digital copies as well).
 Last labs, regardless of date.
 Immunization record.
 Last 3 RN, OT/PT, SLP, Lactation
notes.


Last 3 nursing flow sheets.




Use NICU CAR SEAT
CHALLENGE FLOWSHEET –
Pull into flowsheets using
the wrench function (check
override template order
function)
Do NOT use IP Car Seat
Challenge flowsheet
Document as you were
taught when trained to do
car seat challenges.
File Results.
 Pull







in Procedural Pause Flowsheet:
Use flowsheet wrench tool
Make sure override template order is
checked
Click in blank box at end of flowsheet
list
Click on spyglass
Type “Board” in search box
Click on facility pref list
Accept Procedural Boarding Pass
 Complete
flowsheet by verifying all
relevant information with team in
agreement.
 *It is your responsibility to make
sure everyone is listening during
pause and is in agreement prior to
procedure being performed!
 Use






Code Narrator
Come on, you’re never going to get
used to it unless you use it!
Most Important! Code Start Date and
Time and Code End Date and Time.
All medications usually given during
neonatal codes are listed under
Medications/ Stat Interventions. We
can change the available options to
pediatric code meds by clicking on the
red and blue icon at the top right of
the MAR column.
Active LDAs are already listed; just
add any LDAs that were inserted during
code.
Add staff when you have time; it is not
a problem to add them after the fact.
Vital signs should be entered every
minute during a code.








Change Context to W3DR Labor Triage
In delivery room, click on Delivery Summary in
mom’s chart.
Go to Assessments to document Apgars,
Measurements and any Resuscitative measures
used. The L & D nurse will usually document this
for you if you provide the information to her.
Click on open chart hyperlink at the top of
Delivery Summary flowsheet to access baby’s
chart.
In baby’s chart, use Newborn Navigator:
Admission tab to document vital signs, physical
assessment, ID and safety.
Enter orders: OBGYN Delivery Room Newborn
Admit Orderset. Sign as per protocol cosign
required, using pediatrician’s name (L & D nurse
can share this information with you).
If risk factors present (utilize Initiate Protocol
prompts at bottom of OBGYN orderset), initiate
the specific mini-orderset that applies to your
patient.
Document Vitamin K and Erythromycin in EPIC
using Barcode scanner. Order must be entered
before you can chart these medications!

Add the signed/ held column to your patient
list:





Click on properties -> In left column, scroll
down to signed/ held and click on it -> click on
ADD in center of box -> in right column, scroll
down to bottom where signed/ held is now
located, and click on it -> click on the UP
arrow on the right until signed/ held is at the
top of your list
When an icon appears next to a patient’s
name in the signed /held column, that
means you have signed and held orders. Go
to order management and click on signed &
held orders at top of screen. Then click on
edit and release signed and held orders.
If a header like Post Op shows, but no
orders, click on the arrow next to the
header. This should open up the orders for
review. Click the top open box to select all
the orders and then “release”.
You will then need to go to active orders in
order management to delete any duplicate
or unnecessary orders.
If we release these orders at the proper
time, you will not have duplicate orders,
just the orders you need to care for your
patient.
MAR Documentation: If you have a
medication due at 0200, reschedule
it for 0300 and place in the comment
section: “time change due to
daylight savings time”. If you have a
q1 hour medication due, chart the
0200 dose as not given and then
enter the comment of “due to
daylight savings time”. Then chart
at 0300 for the next q1 hour dose.
 Vital Signs: skip the column for 0200
and add a comment “Daylight Savings
Time” in 0200 if you wish and then
chart under 0300.
 Continuous Infusions: Skip 0200, add
a column for 0300 and DO NOT use
calculator. Simply enter what should
have gone in in one hour under
0300.

 The
Body Cooling Playbook will
be your best source for when
to do what. Do NOT trust the
row information available in
EPIC.
 Add therapeutic hypothermia
flow sheet using wrench
function.
 Document all required
temperature settings, vital
signs, and neurological checks.
 Utilize NICU assessment flow
sheet for expanded
neurological checks.
 CAREPLANS
SHOULD BE INTIATED
ON ADMISSION AND UPDATED
EVERY SHIFT.
 UNDER THE SHIFT ASSESSMENT
ACTIVITY, CLICK ON CAREPLAN
GOALS.
 DOCUMENT PROGRESSING, NOT
PROGRESSING OR COMPLETED AS
AN OUTCOME FOR EACH GOAL.
YOU CAN DOCUMENT THEM ALL
AT ONCE OR INDIVIDUALLY.
 THE PROGRESS NOTE SHOULD BE
A 2-3 SENTENCE OVERVIEW OF
HOW THE PATIENT IS
PROGRESSING TOWARD THE
GOALS.
To add a info in the Care Plan activity using the
Apply Template button:
1. In the patient’s chart, select the Care Plan activity.

2. In the Care Plan activity, click the Apply
Template button (not the New Problem
button!)

3. Search for the template you want by
name. Select the appropriate template and
click Accept.

4. Using the checkboxes, select the pieces
of the template you want to apply to the
patient’s chart and click Accept.
Please be choosy as to what pieces you add.
Remember, you will be charting on these
careplans for a long time!
Select “Create New” to add a learner.
To add education titles:
Under “Unresolved
Education” tab, select Add
Title.
For newborn education, type “Newborn” in
the search box. Select the desired title and
click accept.

Newborn



Newborn Care
Breastfeeding
Bottle Feeding

Pediatric




Peds General Education drops in on
every patient.
You can choose to use this or delete
the Peds General Education and add
the Newborn title instead.











Congenital
Heart Disease
Endocrine/Elect
rolyte Balance
Gastrostomy
Tube
General
Education
GI Education
Heme/Immune
Education
Integumentary
Musculoskelatal
Nasogastric
Neurological
Nutrition
Respiratory
Sepsis
Tracheostomy
General Surgery
The boxes that were
selected creates an
individualized
education plan.
Select the pertinent
education points by placing a
check mark in the box.
Click Accept when complete.
Select Add Point and type
in education point.
When completed, select
Accept and File.
Identify the learner, readiness,
method and response.
Select the
individual point
that needs to be
documented on.
Once it is documented that the learner
understands, a check mark will appear
next to the education point indicating
that this point has been completed.
To document on more than one
education point, select the
multiple button.
Once completed, select the
file button.
 IF
VITAL SIGNS ARE NOT
“PULLING” INTO EPIC, CHECK TO
VERIFY THAT THE VITAL SIGN
FLOW SHEET IS SET TO 1H AT THE
TOP OF THE PAGE AND “HIDE
DEVIDE DATA” IS DISPLAYING AT
THE TOP BANNER.
 CLICK ON THE DOWN ARROW
NEXT TO THE HIDE DEVICE DATA
BUTTON AND THEN CLICK ON
ASSOCIATE DEVICES.
 IF NO DEVICES ARE LISTED
(USUALLY LISTED AS NICU FW20114 FOR ROOM AND BED) THEN A
CALL TO BIOMED AND EPIC
SUPPORT IS REQUIRED.
 Let
me know what else you
need!
~Ilona x5849