FAQ
Question
PAIN
Will Pain interventions be
shown with assessment?
What about when patient
refuses medication?
Answer
Use Pain/CDR Tab or ALL DOC to see assessments & interventions together
**Please note if you are giving medications, you do not have to document this
intervention. It will be reflected in Admin-Rx, MAR & WIZ orders.**
See hover in interventions:
Reassessment being located
under pain but above all the
other assessment fields, why
not above pain @ the top of
this tab?
What if my patient is asleep
on reassessment?
Decision has been made to always chart a pain score for the pain
assessment/reassessment. You cannot just say unchanged for Pain. (However,
Pain reassessment policy does NOT require pain reassessment more than once
per shift unless the patient has had pain or a pain intervention – in which case
a post intervention reassessment is required.)
Pain Asmnt w/o scale:
How do a document a reassessment after pain
medication is given
NEURO
What about RASS
requirements?
Document a new score. It is not necessary to say improved, coping, tolerable,
etc.
If there is an order for q4h
neuro checks, will we chart
the neuro assessment q4h?
Yes
Does GCS have to be charted
on every patient?
CARDIAC
Where is documentation of:
CVP (central venous pressure)
No. It should be charted according to unit policy or provider orders. It is a
mixed case (not all CAPS) & therefore is not required charting on all patients.
RASS documentation requirements have not changed.
See hover for more details:
In ICUs, CVP is generally done from the pressurized invasive monitoring line to
that documentation is done under the art line assessment (which includes
CVP reading in VS
What about Zero transducer?
Waveform?
options about things like dampened wave forms, etc.) Zeroing transducer
before documenting a value is standard of practice and does not need to be
documented.
When CVPs are monitored outside of ICUs, they are generally done manually
with a manometer and there is no waveform or transducer involved.
Where do I document
hyper/hypotension for BP
alteration?
Vascular
Under vascular assessment for
edema could there be a way
to chart edema without
pitting?
This is a medical diagnosis. Your charted VS will suffice for supportive data for
this problem.
Non-pitting is an option:
“Generalized Edema” is no longer available
Use “Other Edema” and annotate as needed
RESPIRATORY
How do you document numerous
chest tubes?
What is Respiratory
Monitoring (Interventions)?
Is that pulse ox?
For Re-assessment: If lung
fields are clear, but cough still
present, do you chart the
cough (not a change)?
GI
How do you document Bowel
Mgt systems – flushing,
Initiation, status
RENAL
SKIN
Where do you document
poor skin turgor? I.e.
decreased elasticity that
you would see w/
dehydration?
Basic drains?
In Respiratory Interventions, there is a place to document up to 5 different
chest tubes. (These are not under the Tubes and Drains section but are
separate and documentation about Chest Tubes is NOT changing with new
build.)
Monitoring respiration via bedside monitor, Covidien monitoring (SaO2,
ETCO2), continuous pulse ox, etc. See hover for more details.
Choose “unchanged except” and annotate that lung fields now clear. If this
improvement were noted near end of the shift, the Patient Response to Care
would be another option to note that some aspects of Resp. status improved.
**Return to clear will be added as an option**
GI interventions – “Bowel Mgt. care” means you provided care as specified in
BMS procedure. No need to spell out each element.
“Skin color/condition” – skin category.
Documentation of most drains and tubes has not changed (it is done in site
management style like IVs and wounds). Can be located in Skin category.
How do you document on a
wound/drain/ostomy?
Pressure Ulcer
Care/Intervention: When
you click the done box are
you documenting that you
did all the things on the
algorithm for that stage PU?
A wound/drain/ostomy are still started from the blue link as before.
Once you “start” a new site, the assessment fields to document ongoing
assessment become available.
The PUPs and Pressure Ulcer Care Guidelines specify that interventions are done
as appropriate for the patient.
Where are therapy beds?
Most units’ standard beds ARE therapy beds. For something more than the
standard bed for the unit, Skin Breakdown Care drop down options include
reasons various kinds of specialty beds are used (for moisture control, pressure
redistribution, friction/shear reduction). If bed type annotated, should be done
only once when patient placed on bed initially.
Where do I document
diaper change/diaper rash
care?
Document appropriate output
Perineal care can be found in:
Lines/IV Other
There are normal listed
when documenting IV site
appearance- are there
supposed to be?
What if an IV infiltrates?
AV fistula?
Yes “Normals” (dry/intact) for initial assessment of shift
Please note that “IV site check” box is no longer available. The IV site should
continue to be assessed per policy, but the documentation requirements have
changed. Document assessment with initial shift assessment. Document if any
changes occur.
There is now a place to document the last IV site check when you discontinue an
infiltrated IV. You should continue assessing & documenting on the “ended” IV
line after an infiltration.
IV Other
Activity/Musculoskeletal
Where do I chart HOB
elevated?
Where do I chart
ambulatory aides?
In Activity/ Musculoskeletal Interventions, under positioning interventions.
Musculoskeletal Interventions:
Fluid/Nutrition
Where do you document poor
If it is a priority problem, Nutrition Goals include options for meal % intake.
appetite? Where can you document Annotate if not priority problem.
that the patient is not eating much? Nutrition sub score of Braden also includes information on nutritional status.
Where do you document % of meal
intake?
FALLS/SAFETY
Where do you document
emergency equipment at the
Bedside?
Fluid/Nutrition “Food Intake” In Assessments, Interventions, All Docs or VS I/O.
Having appropriate safety equipment (e.g. Ambu bag w/ appropriate sized mask
for all patients; extra Et tube or Trach as appropriate) at bedside is part of the
basic standard of care and does not need to be documented. In the Safety/Falls
Interventions section, there are safety interventions that include a very small
number of items including wire cutters.
Fall Risk/Safety: When
does this need to be
charted?
**Falls Risk assessment, status & fall/injury precautions are documented once
per shift for VCH & VUH**
Where do I chart sitter at
bedside?
Sitter at bedside can be found in Falls/Safety interventions: Suicide precautions
or Injury precautions
VCH: Graf-Pif Falls Screen (or check box for <12 mos) & Fall Risk Status are
documented once per shift
**Please note q1-2h “Falls Safety check” is no longer required. You will continue
your safety rounds, but the documentation by checking the box is not required.
As always, document any fall event.
VUH: Morse Falls Risk Screen is documented on admission, following a fall event
or significant change in status. There is no longer a “status” field.
Medication
What exactly is the
Medication Assessment?
Self-Care
Where do I document
hyper/hypotension for BP
alteration?
What does Instrumental ADL
Deficit mean?
Infection
What does “Enhanced
Precautions” mean?
Psychosocial
Re-Assessment
In most acute care units they
are not documenting a reassessment one other time in
their shift – are we going to
change this standard and make
them document the reassessment one other time?
DEVICES
Where is Pacemaker
documentation?
This is where the nurse uses his or her judgment to review available data from
MLT, orders, etc. and determine is the patient has a medication risk. Many
patients do have a risk (e.g. Patients on anticoagulants, antihypertensive, chemo,
nephrotoxic antibiotics, etc.) But this may not necessarily be a priority problem
for most patients. Someone admitted specifically to treat complications from a
medication interaction or under-/over-dose, this may be a priority problem.
This is a medical diagnosis. Your charted VS will suffice for supportive data for
this problem.
Per Saba definitions: ADL Alt. - complex = "Change in or modification of more complex activities
than those needed to maintain oneself." I think this includes ability to drive, shop for groceries,
cook, manage money, etc.
http://www.mc.vanderbilt.edu/root/vumc.php?site=infectioncontrol&doc=32961
Patient Response to Care entry could replace documentation of “Unchanged” on
Acute Care Units. With “Unchanged Except”, you’d need to chart the changes.)
See Device Tab
Berlin fields? (artificial heart)
Berlin fields will only show on units where those kinds of patients are admitted
(primarily adult and pediatric cardiac ICUs).
Alarm limits?
There is a place at the bottom of the Device Tab to document Alarm Limits BUT
we are not sure this is necessary. This is being looked at by Clinical Practice.
PLAN
Why don’t we have the
ability to say each goal is
either met or not met?
Can goals be in the same as
assessment/problems?
How do I know what goals
to set?
Are Falls & Pain required to
be priority problems?
Why Discharge Readiness & DC Plan
reviewed? Are Both necessary??
MISC
Are the ECMO, CRRT tabs
staying?
ICUs: Do we still have to
document q2h?
What is not included in ALL
DOC?
Can WEL and OEL be
selected as priority
problems?
In many cases, the answer is not just “yes”. By using a narrative entry under
“Patient Response to Care”, richer detail can be included (e.g. What interventions
did/did not contribute to improvement? If goal was not fully met, what would
you recommend the oncoming nurse try based on your experience?) This is one
of the key ways documentation “tells the patient story.”
Goals were taken from most frequently annotated goals by RNs in previous
charting & will not be changing much. Some may be named differently from the
assessment categories, but once you familiarize yourself with the predefined
goals, this will be a much simpler process than before.
Goals should match your 1-2 Priority Problems as indicated in red on the plan tab.
They are not required. You should pick the top 1-2 priorities for your shift. If
there are priorities greater than pain/falls, it is ok to pick those. You will continue
to do your safety education & precautions, but it does not have to be made red
indicating it is a priority if there are higher priorities.
"readiness" is assessment; "reviewed" is plan reviewed;
Review/revision of plan is required q 24 hrs.; readiness is assessed q shift
Yes. Access from the “Chart” button if the tabs are not showing:
Assessment does not equal documentation. When unit-specific policies require
assessment at specified intervals (q I, 2, or 4 hrs.) the assessments are done at
least that frequently. Unless the unit-specific policy requires documentation of
that assessment at a specific interval, the documentation policy required
documentation of focused reassessment at least two more times during the shift
for ICUs. Vitals, I&O, Interventions, and device documentation is done in real
time/near real time.
I/Os, PEWS, Devices (unit specific items)
This is to prevent a long loading time for the ALL DOC tab
It IS possible to have the assessment of a category be WEL (NOT WNL) but for
there to be a priority problem for that category.
Examples:
-Pt. admitted with Cystic Fibrosis and infection for 14 days IV Antibiotics. The
reason the pt. is hospitalized is to treat the Resp. Infection 2ndary to her chronic
CF and she will always have ineffective airway clearance due to her disease.
However, today her Resp. Assessment is completely clear – no abnormal breath
sounds, no cough, no sputum. Would document WEL since her baseline will never
be “normal” and continue to have Ineffective Airway clearance as a priority
problem.
-Pt. admitted following a skull fracture for monitoring for possible concussion. He
is at risk to develop a Neuro problem but today, his neurological exam is
completely normal. He has no other significant problems. Recommendation is to
document WEL for his assessment (since a skull fracture with risk of concussion is
NOT normal) and to mark that as significant. It would also be acceptable to
identify a Neuro problem and since it might be a risk rather than an actual
problem, they could annotate “risk for” if they were uncomfortable documenting
and actual problem.
What if the assessment
category does not need
supporting data for OEL or
Problem?
Supporting data is not always required for every OEL or Problem. Some “stand on
their own” such as Nausea (no emesis, abdomen normal).
Supporting data should be charted if applicable.
IAEs: Nurse reported that
she charted her assessment
and saved it but received an
error when trying to save
her interventions.
If you change the time before you start charting, this will decrease the odds of
getting IAEs.
Using “modify” should eliminate IAEs
If you “overlay” charting fields, you will get IAEs.
Will I be able to copy my
assessments from shift to
shift?
Is it possible to have HED
default to exact time with the
option to change to collapsed
time versus defaulting to
collapsed time?
Decision Pending
Does WEL have to be annotated
every time?
ONLY on admission. This is baseline, just like before, it is only required to be
annotated on admission & if the condition changes. Use “show all results” to
make sure it was annotated on admission (or at least once prior).
To see charting in actual time, simply click the “Chart” button.
You can also see actual times by using “Show All Result Values”
TIPS
If you are unable to find an item, go to the ALL DOC tab & use the “Add” button.
It will help you search to easier locate items.
Don’t forget to SHOW ALL
So that you do not miss important required elements!!