Summer 2014
Attention ED Staff! The
Education Committee
decided that this newsletter
would be dedicated to
providing helpful hints from
the nurses and tech to you.
They range from charting
tidbits to how to find classes
via Professional Resources.
All the articles are little ways
to make your job easier!
Education Committee Newsletter
USE: Non-judgmental terminology,
medical terminology, facts
DO NOT USE: Name the nurse/staff
involved, opinions, slang/unofficial
terms
Post-Fall Documentation: VS and Pain
Assessment,
Updated
Fall
Risk
Assessment
and
intervention
expectations, Significant Note penned
by RN, Significant Note penned by MD.
Helpful Hints
You must chart “Patient seen by
provider only. No Nursing assessment
done.” for Supertrack and IW patients.
EPIC has the capability of “.phrases”.
You can create these phrases in the
“Quick Note” screen. You can create a
standard statement for IW and
Supertrack patients to make your life
much easier when working up there.
Ask any of the Education Committee
members if you need help with this.
Critical Care Documentation
OB Patients to L & D:
By: Ryan Morissette
By : Emily Lloyd
Nursing documentation for critically ill
patients can be difficult and complex
but is essential for safe and effective
care. The use of the Code/Critical-Care
Narrator can help to guide nursing
documentation that is clear and concise.
As it is still a newer tool, some people
are still hesitant with its use, but with
time and repetition it can be a great
asset for communication and care. As
litigation continues to be on the rise,
especially with critically-ill or injured
patients, accurate and timely
documentation is paramount.
Any patient that is going to L&D that is
registered in the ED needs a disposition
once we decide to send them there.
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If and only if the patient is
sent directly from pivot (their
name on the board, cannot
be in an intake room, IW or
any where past our expected
board), we just have to hit
the radio Triaged to OB
Any other time a patientis
sent to the 4th or 5th floor,
they want the patient in their
“Expected” patient list. This
lingo for them translates to
us to actually order “Tranfer
to L & D”. You must fill out
the order like a bed request (
floor status, OB attending).
Even if the intake MD
doesn’t see the patient nor
physically move them to a
room, if their name is moved
anywhere on the board, this
order is a must!!!! Anyone
can place these orders.
Fall Documentation
By :Jennifer Comer
If your patient falls:
Document a significant event note in
the chart in addition to submitting a
Safety Intelligence report.
Supertrack
By: Amanda Puhal
For Supertrack charting, the RN only
needs to complete the “Rapid Intake”
and “Extended Intake”. This charting will
take you through vital signs, assigning
an ESI level, add medical/surgical
history, allergies and medications. Any
patients with an ESI of 4 or 5 need only
this documentation.
Those patients in Internal Waiting(IW)
who will be discharged from there don’t
need an intake. Before giving
medications, please verify allergies. The
intake provider should have done this
already but it can’t hurt to ask again.
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Though it may not always be possible,
the goal is “real-time” charting so that
the information does not have to be
recalled and reconstructed. As time
passes and more events or distractions
occur, it becomes more difficult to
create the best chronology of events for
other providers. The nursing
documentation of interventions and
care helps to guide patient treatment,
and thus, needs to be an accurate
representation of the patient status.
We all should strive to be as descriptive
as possible and to illustrate the full
picture of patient care while in the
emergency department. Be sure to
document all nursing assessments,
interventions, and evaluations of
treatments. It is best to complete a
head-to-toe assessment on all critical or
code patients as they generally have
more than one body system is involved.
Even in situations where an assessment
Summer 2014
may include “WDL (within defined
limits),” the visible options should be
documented to verify they were
completed. It is always better to over
assess your patient than under assess
and miss something important. As in
nursing school, “If it wasn’t charted, it
wasn’t done,” is true for all nursing
documentation.
QUICK DOCUMENTATION TIPS:
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Document conversations and
notifications to provider
Record all changes in patient
status (mentation, vital signs,
response to medication, etc.)
Use free text/blank notes to
articulate complex issues or
events
Be confident in your
assessment skills and
document accordingly
Be consistent with all
documentation
Be clear, concise, accurate,
and relevant
Utilize Code/CC Narrator and
become familiar with tools
Make sure vital signs are
complete and recorded per
patient condition
Remember, it is okay to ask for help,
and to have someone check/ verify the
completeness and accuracy of your
chart. Nursing documentation has the
ability to improve patient care and
outcomes through communication and
recording all aspects of care. Attempt
to document so someone without any
knowledge of patient could read it and
get a complete picture without ever
seeing the patient. Protect yourself and
your patient by documenting to the best
of your ability. It can also help to read
others documentation, if appropriate,
and learn other skills or techniques.
Most importantly, when in doubt, it is
better to over chart than under chart.
Education Committee Newsletter
Helpful Hints
ED Tech Charting at Pivot
Trauma Documentation
By: Nicholaus Mohr
By: Becky Davis
There are three scenarios in which the
Lead Pivot tech would have to
document a patient wanting to leave
the emergency room without
completing their care. 1) When a
patient is registered by the CTA but
does not get seen by the intake doctor
for whatever reason. In this case, the
form that is entitled, Informed Consent
to Refuse Examination or Treatment,
must be filled out. It must be signed by
the patient and the Lead Pivot Tech and
put with the rest of the patient’s chart
to be scanned in. 2) We would
document when a patient was
registered by the CTA and seen by the
intake doctor and for whatever reason
decides that they do not want to
continue their care. In this case, the
Lead Pivot Tech would fill out the form
entitled, Discharge Against Medical
Advice. On the form the intake doctor,
patient, and a witness must sign the
form. The witness can be the Lead Pivot
Tech. It must be filled out completely
including the patient’s name, the intake
doctor’s name, the advisable condition,
and the possible risks of not continuing
the patient’s care. The form should
then be placed with the patient’s chart
and scanned. Along with these forms a
blank note should be documented in the
patients chart explaining the patient’s
reason for wanting to discontinue care,
how we encouraged the patient to
continue their care, the intake doctor
was contacted, the proper paperwork
was filled out, and anything else you
feel would pertain to the encounter. 3)
A scenario which we would document a
patient not continuing care would be
when a patient does come to the CTA
desk or approaches the Lead Pivot Tech
and asks questions pertaining to their
care but decides not to register and be
seen. In this case a short email
explaining the encounter with the
patient and a brief description of the
patient should be e-mailed to April
Koehler, Clinical Nurse Manager.
Summer and Trauma Documentation
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Summertime in Aurora, Colorado, can
you think of a better time to practice
and perfect your Trauma
Documentation. People are getting
pummeled by 500 pound boxes and
ending up with liver lacerations,
motorcycle collisions, falling off horses,
patio’s, balconies and out of trees.
During this time of year, we get a huge
variety of trauma including the GSW’s
and stabbings.
One way to get to be familiar with the
trauma recorder is to use it for all
trauma documentation. Falls, bicycle
collisions, jumping on trampoline
fractures, the trauma recorder is not
only for Trauma Alerts and Trauma
Activations, it can be utilized for all of
your trauma charting for any patient
that has a trauma event. All you have to
do is stop the trauma start and then
enjoy the use of all sorts of assessment
and procedure and mechanism helps
that the trauma recorder can provide
for you. One of the best ways to get
proficient with your trauma
documentation is to practice on simple
traumas, assaults, falls and small trauma
when there is no stress while you are
learning the trauma chart. Our partners
in the Trauma Service are encouraging
us to use the trauma documentation for
all of the trauma situations we
encounter. The plus of using the
trauma recorder is that as the patient’s
true story unfolds the trauma recorder
will help you to find and document all
the injuries. It frequently occurs that as
you get into what really happened to
your patient that they end up being
eligible for a Trauma Alert or even a
Trauma Activation.
Talking with Regina Krell RN with
Trauma Services, I found out that we
are doing very well on much of our
trauma documentation. The orange
trauma sheets we provide during
Trauma Activations and Trauma alerts if
filled out show the staff all that is
needed basically for the beginning
Summer 2014
charting. If you check off your sheet
you will be doing well. The area we still
fall short is repeat Glasgow Coma Scale
and repeat temperatures at one hour.
Trauma charting helps us present the
mechanism, injuries and solutions we
finally end up with a diagnosis and what
ways we can teach for care and follow
up. For example, an older patient with
rib fractures, the need for incentive
spirometry teaching. Please chart all
your wound care, crutch walking and
any teaching that you will be doing for
your patient.
One other help that may assist you with
trauma is the TNCC course and ENPC
course from ENA. The course is new
this year with the 7th Edition and there
are a lot of new concepts coming out on
Trauma. I encourage everyone to take
the course, it is very interesting the
changes that have occurred in the last 5
years. Finally, have a great summer and
stay safe.
EMTALA Documentation
Requirements
By: Cat Bergstrom
When transferring and patient out of
the ED to another facility (Children’s,
Psych, Kaiser) EMTALA documentation
is required by the Center for Medicare
and Medicaid.
In EPIC, hit the “Transfer” button to the
left of the screen. It will give you three
options for charting. Fill out the
“Transfer Documentation Checklist”.
This consists of the RN you called report
to, the mode of transportation (Life
Link/Rural Metro), ACLS or BLS, Vitals
Signs within 15 minutes of transfer and
Time/Date of Transfer.
A PCS form is also required. The easiest
way to access the document is to go to
“Quick Note” in EPIC. Type in “PCS” in
the search window and fill the form out,
hitting F2 as you complete each section.
You then go to “Chart Review”, select
the “Notes” tab and your PCS document
should be the first document at the top
of the page. Open it and select the print
option.
Education Committee Newsletter
Please make sure to send the ORIGINAL
M1 paperwork, copies of labs, provider
notes, EKGs, and radiology disk if
applicable.
Helpful Hints
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2.
ULEARN
UCH Continuing Education
web page on the HUB
ULEARN:
CDU Documentation
By: Erin Pillette
When a patient is assigned to the CDU
it’s very important to have all the key
components in your chart. Before
accepting care of this patient newly
assigned to the CDU, review the chart to
ensure that all the main ED
documentation has been done. Once
the patient comes from their room, the
charting changes a bit from the typical
“main” ED charting.
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Start at home on the HUB
Select TRAINING &
EDUCATION on the right sie
of page
Select ULEARN via Lawson
Self-Service
From ULEARN, click on
LEARN link at top of page
Click on All Courses on left
side of page
Select Optional Learning tab
Search by name (i.e. PALS)
UCH Continuing Education
First off, the CDU chart is done under
the “Obs/IP Assessment” narrative. You
chart Your assessment upon admission
and per shift. You need to document a
focused assessment such as
cardiovascular if there are admitted to
the CDU for ruling out ACS. Next,
document the screenings: nutrition,
functional, psych/social, and the braden
scale. Every patient should have a new
set of vitals as well as vitals every four
hours, unless otherwise ordered by the
provider. Don’t forget at the end of
each patient’s stay, no matter where
they are located in the ER, there should
be a documented departure condition.
This includes charting a last set of vitals,
how they left, and if applicable the care
handoff. There’s not too much to it, but
none the less, all of these steps are
required while caring for the CDU
patient
Continuing Education
Classes:How to sign up
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Use the link below for a list of CE
offerings
http://hub.uch.edu/news/2013/contin
uing-education-courses-/
Help with Reimbursement
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By: Hesper Smith
UCH values education and encourages
its employees to pursue continuing
education by offering an annual
allowance of up to $1,200. Here are
some helpful ways on the HUB on how
to sign up for optional classes as well as
certifications and renewal certifications.
There are 2 ways to search for classes:
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Start at home on the HUB
Select the Training and
Education link on right side
of page
Select UCH Continuing
Education link
Click on Classes and Events
tab near top middle
Narrow your search by
Event, Topic, Region or
Location
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Start of the HUB
Select Benefits and Payroll
tab on left side of page
Click on the UCHealth
Benefits site link
Follow the link for Education
Assistance/Continuing
Education
Access the Edcor Online
System to request
reimbursement
Summer 2014
Education Committee Newsletter
Sedation Narrator
By: Tre Andres
Conscious sedation is defined as "a
technique of administering sedatives or
dissociative agents with or without
analgesics to induce a state that allows
the patient to tolerate unpleasant
procedures while maintaining
cardiorespiratory function." Basically to
make someone unaware of the fact
you’re about to put their shoulder/hip
back in place. When doing any
conscious sedation in the ED use the
Sedation Narrator tab in EPIC.
Opeiing the Sedation Narrator brings
you to a start time.
When doing your pre-procedure
charting ensure that you get a baseline
ETCO2 along with the rest of your
assessment.
Account for everyone present for the
procedure just as you would a code or
trauma.
When giving medications make certain
administration times are accurate.
Remember that intra-procedure VS are
Q5
Once procedure is completed chart your
post-procedure assessment, charting VS
Q15 for the first hour post procedure.
Chart you Critical Care Time once
patient has a PAR score equal to or
greater than 10.
Upon procedure completion click on File
and Exit, this will give you a stop time.
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Helpful Hints
Summer 2014
Education Committee Newsletter
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Helpful Hints!