Toolbox
Questions – Answers - References
REF #
1
KEYWORDS
Functionality
Policy
Clinical
practice
Efficiency
Optimization
Copy forward
QUESTIONS
What issues
should be
considered
related to
‘copy
forward’?
ANSWER
Copy forward may be used very
carefully. Clear policies covering this
use should be available.
When making this decision, the
following should be considered:
REVIEWED BY
(TASKFORCE MEMBER)
Melissa Barthold
Lisa Bove
Jim Cato
Brenda Kulhanek
DATA OR EVIDENCE?
Evidence and dataSurvey Results:
(date)
REFERENCE/SOURCE
http://journal.ahima.org/200
8/06/04/an-appropriate-useof-copy-forward-with-acaveat/
Discussion on CARING list
Stakeholders in the decision: CNO’s,
Practice Councils, Risk Management,
Legal department.
Review of software to determine
functionality – clinical IT and clinicians
Is ‘copy forward’ present in any
application currently?
What data is copied forward – and
what is not allowed to be brought
forward?
Is there a standard in place?
7
Hardware
Mobile
Portable
devices
Criteria for
selection
Storage
Power
Hallway
Fire codes
State
regulation
What are
current
practices
related to use
and storage of
mobile
documentatio
n devices such
as rolling
computer
carts?
How is validation accomplished? How
the caregiver is assured that the data
is not simply copied forward, but is
reviewed prior to storing the data?
To be considered:
Instruct staff to move mobile devices
from hallways into alcove or nurses’
station to comply with fire/state
regulations.
For design/redesign, consider creating
elevated floor with outer perimeter
docking or alcoves that includes
power/network drops.
Consider wireless.
How are devices flexed in response to
staff or patient census. What area is
Brenda Kulhanek
Lisa Bove
Melissa Barthold
Portia Towns
Page 1 of 28
Data
CARING list July 2009
DATE
April, 2009
Toolbox
Questions – Answers - References
REF #
3
2
KEYWORDS
QUESTIONS
ANSWER
Fire
Regulation
Design
Ergonomics
Are mobile
carts (COW’s,
WOW,s, etc.)
allowed in the
hallway?
available for parking the devices to
maintain power?
Place outlets/network drops at an
ergonomic height.
Physiological
data
Monitors
Data
validation
Interface data
capture
Policy
Practice
Optimization
Should
physiologic
data imported
from monitors
be validated
before data is
it stored in
the EMR?
Any physiological data imported from
monitors into an electronic
documentation system must be
approved or validated by the nurse
prior to its storage in the EMR.
Electronic
Signature
HIPPA
Documentatio
n
Policy
Practice
How is the
electronic
signature
defined?
Issues: Validating that data is correct
coming across an interface
Ensures clinician evaluation of the data
prior to storage and provides the
ability to observe trending or to
correct technical issues, such as lead
artifact or monitor/interface issue.
Electronic signature is legal in all 50
States and the security standards of
electronic signatures are addressed in
the security and privacy provision of
the Health Insurance Portability and
Accountability Act (HIPAA).
REVIEWED BY
(TASKFORCE MEMBER)
DATA OR EVIDENCE?
Brenda Kulhanek
Lisa Bove
Melissa Barthold
Portia Towns
Data-
Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove
Portia Towns
Portability and
Accountability Act
(HIPAA)
It can be an electronic sound, symbol,
or process associated with a record.
It can be an automatic signature added
by a system when an entry is saved by
the user or it can be an intentional act
of signing an electronic document.
It is an electronic indicator added to
the electronic medical record, including
flowsheets, orders, notes, etc. that
indicates signature of the licensed
provider. It may not require additional
Page 2 of 28
REFERENCE/SOURCE
Discussion on CARING list
CARING list
Portability and
Accountability Act (HIPAA).
http://www.hhs.gov/ocr/priv
acy/hipaa/administrative/sta
tute/hipaastatutepdf.pdf.
DATE
Toolbox
Questions – Answers - References
REF #
KEYWORDS
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
separate action (such as re-entry of a
password) – it may be as simple as the
act of saving the data entered is the
‘signature’.
HIPAA-covered entities that use
electronic signatures for transactions
must adhere to U.S. Department of
Health and Human Services electronic
signature standards. The software
program must provide:



4
Documentatio
n
Standards
Policy
Practice
Requirements
Design
Minimum data
sets
What should
be considered
when
designing
electronic
documentatio
n?
Nonrepudiation - assurance
that the signer cannot deny
signing the document in the
future,
User authentication verification of the signer's
identity at the time the
signature was generated, and
Message integrity - certainty
that the document has not
been altered since it was
signed.
When making this decision, the
following should be considered:

Build documentation that reflects
standard practice and regulatory
requirements. Examples: Minimum
data sets from nursing
organizations, Joint Commission,
CMS and the Bureau of Vital
Statistics.
Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove
Page 3 of 28
DATA OR EVIDENCE?
REFERENCE/SOURCE
DATE
Toolbox
Questions – Answers - References
REF #
KEYWORDS
QUESTIONS
ANSWER

Who is going to view/utilize the
data? Only collect data that is used
by the care team or regulatory
requirements.

Purpose of documentation:
o Communication among
caregivers
o Support of billing
o Potential for research
o Longitudinal record of
patient’s health status and
treatments

Support documentation of
assessments and treatments that
reflect the standard of patient care
as established by local, state and
national regulations

Guides staff to document the “right
things” by preventing
documentation of the “wrong
things” through proper design

Guides staff to document the “right
things” by preventing
documentation of the “wrong
things” through proper design
REVIEWED BY
(TASKFORCE MEMBER)
Suggestions:

Documentation Categories:
o Assessments
o Interventions
o Biometric data
o Summary/Evaluation data
o Progress Notes
o Care Plans
Page 4 of 28
DATA OR EVIDENCE?
REFERENCE/SOURCE
DATE
Toolbox
Questions – Answers - References
REF #
KEYWORDS
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
Demographic data
Patient education
Communication to
members of the patient
care team
o Communication between
members of the patient
care team
Format of documentation
o Easily viewed
o Supports efficient
documentation
o Ability to obtain data for
reporting (limited free-text
fields)
o Consider all disciplinesdocumentation needs and
access needs
o
o
o

5
What type of
format should
be used to
indicate errors
or changed
documentatio
n?
Should the
older data be
displayed?
How is the
completed
history of data
configured?
(audit trail)
Is this vendor specific?
Can it be configured to one standard?
CHIT standard?
HIM standard?
Risk Management?
“Error
explanations–
Page 5 of 28
DATA OR EVIDENCE?
REFERENCE/SOURCE
DATE
Toolbox
Questions – Answers - References
REF #
KEYWORDS
24
6
Devices
Device
configurations
Hardware
QUESTIONS
changes –
how much
should be in
strikethrough
format? Or
should it be in
that format?”
What policies
should be
addressed
prior to
electronic
documentatio
n
design/imple
mentation?
What are the
best devices
and device
configurations
that support
nursing
workflow?
ANSWER
When making this decision, the
following should be considered:
Do you support point of care (real-time
at the patient’s side) charting?
REVIEWED BY
(TASKFORCE MEMBER)
DATA OR EVIDENCE?
REFERENCE/SOURCE
DATE
Data
Melissa Barthold
Brenda Kulhanek
Jim Cato
Lisa Bove
Trish Gallagher
What applications are currently in use
and what are planned?
If you are using electronic medication
records with bar coding, do you need a
place to store individual medications?
CARING list
Most of the responders have hit on the
main device pros and cons. There is no
magic device (yet) that does not have
some drawbacks, i.e screen visibility,
battery life, wall space, hall space, etc.
We tried our best to put devices in
each room but were limited by the age
of the facility and available wall space.
Page 6 of 28
Sept 23, 09
Toolbox
Questions – Answers - References
REF #
KEYWORDS
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
We went live with clin doc in June. In
addition to some WOWs and wall
mounted devices in the halls from an
earlier phase, we added "half-a-roos"
with Panasonic One notebook to each
double and quad room. Theoretically,
this provides the opportunity for point
of care charting of I&O, vital signs, etc.
in the room with the half-a-roo acting
like a small workstation, and also
provides the flexibility of removing
the notebook to allow staff to sit at the
bedside to document longer items,
such as an admission or discharge.
Space may be an issue. Bedside
charting should be an expectation
There are many reasons for not doing
point of care charting – culture,
convenience. Success of beside
charting partially depends on how
much change enablement the facility
wants to apply to this practice.
Point of care documentation is not part
of the actual IT project; but is part of
the nursing work process and is
managing by nursing administration.
The bottom line, there is no perfect
solution. Each facility presents its own
challenges.
Device Fair and pilot installation of
prototypes to allow the staff to have
input.
Wall-mounted computers in the
rooms. It took awhile for all to get use
Page 7 of 28
DATA OR EVIDENCE?
REFERENCE/SOURCE
DATE
Toolbox
Questions – Answers - References
REF #
KEYWORDS
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
to documenting assessments, etc in
the room. It may be ideal because if a
patient asks about their labs or other
test results, we can easily pull it up for
them in the room. At the other
campuses, we have had a variety, but
for med admin bar coding in the room
is superior.
A bedside PC may be good for many
things, such as the admission data
base, but should not be the bedside
nurses only option.
8
9
10
Charting
Real time
Point of care
Documentatio
n
Devices
What is the
best practice
for
maintaining
the power
supply on
mobile
devices?
How is the
appropriate
number of
documentatio
n devices
determined?
How is
‘timeliness of
charting’
defined?”
How is this
affected by
the
constraints of
documentatio
n technology?
When making this decision, the
following should be considered:
Was there a ‘timeliness of
documentation’ policy before
automation? Any such policy needs to
be reexamined or created prior to
implementation of electronic
documentation.
Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove
Has timeliness been defined in other
applications such as medication
Page 8 of 28
DATA OR EVIDENCE?
REFERENCE/SOURCE
DATE
Toolbox
Questions – Answers - References
REF #
KEYWORDS
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
administration or ancillary charting?
What type of device (WOW, tablet,
compute in the room, desktop, etc.)
does the user have access to?
Generally, prior to automation,
‘timeliness of charting’ was defined by
the expectation that the clinician would
complete documentation prior to the
end of their shift. With automation,
the focus has moved to ‘real-time’,
although ‘real-time’ can vary based on
the type of device that a clinician uses.
Late charting has been defined
anywhere from 30 minutes (often
based on medication administration
policies) to 4 hours (batch charting
twice a shift).
11
12
Downtime
Paper forms
Policy
Procedures
Are ‘default’
answers in
forms
permitted?
How is the
scope of
default
answers
determined?
What
processes are
used to
document
during a
computer
downtime?
However defined, the policy needs to
match practice.
When making this decision, the
following should be considered:
Do you allow defaults on paper forms
or in other applications?
During a downtime, several processes
must be considered:
1) How will results be obtained on
patients who are currently
admitted? Numerous vendors are
now selling downtime solutions
which reside on stand along PC’s in
order to allow providers the ability
to continue to review current
Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove
Jim Cato
Page 9 of 28
DATA OR EVIDENCE?
REFERENCE/SOURCE
DATE
Toolbox
Questions – Answers - References
REF #
KEYWORDS
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
clinical information on patients. If
this option does not exist, the
development of reports stored on a
local PC which are updated
automatically at frequent intervals
and which can be accessed or
printed when the EMR goes down,
may be another viable option.
2) How will clinicians continue to
document? This is generally
accomplished with the use of
downtime paper forms. Some
organizations will want to revert to
old paper documentation but in
most cases, from a risk
management perspective, the
content of the downtime form
must be consistent to ensure the
same standard of care is provided
during downtime. The
development of downtime
documentation forms are often
part of the project scope.
3) Medications – access to an up to
date list of the patients current
medications along with the last
date/time received and when the
next dose is due is also imperative
documentation during downtime.
The generation of downtime MAR’s
in order to allow staff to continue
to document the administration of
medications is necessary.
Downtime policy and procedures along
with a downtime ‘kit’ containing all the
needed paper forms including order
sets should be easily accessible on
every unit. Also – don’t forget to train
staff on downtime procedures during
Page 10 of 28
DATA OR EVIDENCE?
REFERENCE/SOURCE
DATE
Toolbox
Questions – Answers - References
REF #
KEYWORDS
Downtime
Recovery
QUESTIONS
What data
entry recovery
and backfill
processes are
used after a
computer
downtime?
What are the
decision
making
processes to
determine
what data
gathered
during a
downtime is
backfilled into
the computer
system? What
timeframes
are used to
determine
what data is
backfilled into
the system
and when the
backfill must
be
completed?
ANSWER
the education process.
Part of the project implementation
should include a multidisciplinary focus
group to determine downtime
processes based on different types of
downtime (ie Network, EMR clinical
repository, ancillary systems that are
interfaced etc). The main focus in
determining what information is
entered after a downtime should be
centered around ensuring that risk to
the patient is minimized after a
downtime. It is important to consider:
1. The type of information.
Information such as allergies,
height and weight for
Pharmacy orders and
medication information should
always be back entered since
this is information required for
the care of the patient.
REVIEWED BY
(TASKFORCE MEMBER)
Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove
Jim Cato
2. Who uses the information? Is
the information only used by
one ancillary department or is
it reviewed by numerous
providers to make clinical
decicions?
3. How long has the system
been down? A downtime
which impacts a change in
care providers (ie over a shift
change) may be handled
differently than one that does
not. Often a downtime that is
4 hours or less may be
handled differently than one
which extends longer than 4
hours.
Page 11 of 28
DATA OR EVIDENCE?
Data
REFERENCE/SOURCE
DATE
Toolbox
Questions – Answers - References
REF #
KEYWORDS
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
4. Shat is the impact to it not
being available in the EMR? If
the patient is readmitted, will
the information be valuable to
have in the EMR (ie home
medications, allergies, history
etc)? Is the information
related to the medication
administration process? This
high risk process may need to
be handled differently since it
involves a higher risk to the
patient.
5. What risk exists for the
patient if the information is
not entered?
6. Is there a mechanism to
denote a downtime occurred
in the EMR so providers
reviewing the information
know to reference the paper
chart
More information has been written
about the importance of a standard/
policy regarding how to access data
during downtime than about what to
document after downtime.
Ideally, following a downtime all
patient information recorded on paper
should be electronically entered so that
the EMR is complete and patient care
is not compromised. This however is
not always practical due to the time
required to back chart the data and the
issue of who is responsible if the shift
changes during downtime. Many
hospitals have two standards – one for
a short, planned downtime and one for
Page 12 of 28
DATA OR EVIDENCE?
REFERENCE/SOURCE
DATE
Toolbox
Questions – Answers - References
REF #
KEYWORDS
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
DATA OR EVIDENCE?
REFERENCE/SOURCE
planned or unplanned downtimes
lasting longer than 2 – 4 hours. For
the short, planned downtimes (less
than 4 hours usually), many hospital
require that the nurse and/ or
pharmacy (depending on the data)
back chart the orders, medication
administration and clinical
documentation. Often for the longerthan-four-hour downtime, no backcharting is done.
RECOMMENDATION:
If your facility is not back-charting all
clinical data regardless of the length of
downtime, then make a notation in the
electronic chart directing care givers to
the paper chart for specific
information.
14
Downtime
Clinical
documentatio
n
Policies and
procedures
What is
current
practice for
communicatio
n of
downtimes to
clinical areas?
Early, often and as much as possible.
Post where ever possible.
Login notice, when logging into system
Screen saver communication
Overhead announcements
Email
Managers, for posting
Page to beeper
Potty trainers
Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove
Jim Cato
Never too much!
Page 13 of 28
Drazen, Erica, et al.
Saving Lives, Saving
Money In Practice:
Strategies for
Computerized Physician
Order Entry in
Massachusetts Hospitals
Massachusetts
Technology Collaborative
and New England
Healthcare Institute
January 2009
http://www.nehi.net/pu
blications/38/saving_liv
es_saving_money_in_pr
actice_strategies_for_co
mputerized_physician_o
rder_entry_in_massachu
DATE
Toolbox
Questions – Answers - References
REF #
KEYWORDS
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
DATA OR EVIDENCE?
REFERENCE/SOURCE
setts_hospitals accessed
September 22, 2009
Nelson, Nancy,
Downtime procedures
for a clinical information
system: a critical issue
Journal of Critical Care
(2007) 22, 45–50
15 combin
ed
16
Does
charting-byexception
support best
practice? Is it
legally
defensible?
Charting by exception has been
successfully implemented in many
organizations. Important
considerations:
1. Clearly define normals in
documentation policy or in
documentation system
2. Clearly define proper charting
process and content for abnormals
3. This method of charting cannot be
used to document teaching
4. changes in the patient’s condition,
while still within the normal range,
should be documented
5. Chart on time
6. Charting by exception has been
associated with a decrease in
nursing charting time of up to 75%
7. Meets JC Standards for
individualization of patient care
Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove
"Ladies & gentlemen of the
jury, I present... the nursing
documentation".Full Text
Available (includes
abstract); Austin S; Nursing,
2006 Jan; 36 (1): 56-64
(journal article - case study,
CEU, exam questions) ISSN:
0360-4039 PMID: 16395021
CINAHL AN: 2009089387
American Journal of
Nursing:
March 1999 - Volume 99 Issue 3 - p 24G, 24J
(http://journals.lww.com/ajn
online/Fulltext/1999/03000/
Charting_by_Exception__A_t
imely_format_for_you_.16.a
spx)
Charting by Exception
Applications: Making It Work
in Clinical Settings by Laura
J. Burke and Judith A.
Murphy (Ring-bound - Jan
Page 14 of 28
DATE
Toolbox
Questions – Answers - References
REF #
KEYWORDS
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
DATA OR EVIDENCE?
REFERENCE/SOURCE
15, 1995)
Charting by Exception: A
Cost Effective Quality
Approach (A Wiley
medical publication) by
Laura J. Burke and Judy
Murphy (Paperback - Oct
19, 1988
Charting by exception:
http://allnurses.com/nursing
-student-assistance/helpplease-charting-296172.html
17
What is
current
practice for
enhancement
request
prioritization?
How are
clinical
enhancement
requests
reviewed?
Does the
review of
clinical
enhancement
requests
include an
assessment of
the clnical
impact of the
changes?
What is
current
practice for
communicatio
Page 15 of 28
DATE
Toolbox
Questions – Answers - References
REF #
18
KEYWORDS
Non-licensed
EMR
documentatio
n
QUESTIONS
n of systemrelated
changes,
enhancement
s?
What
documentatio
n by nonlicensed staff
is permitted in
the EMR?
What is
current
practice
related to RN
co-signature
of
documentatio
n entered by
non-licensed
staff? Is the
practice or
policy
enforced
through
technology or
policy alone?
ANSWER
Generally, processes that were
following in a paper patient chart
should be followed in an
electronic patient chart. If nonlicensed personnel documented
in a paper chart without a cosignature and the practice was
within a defined scope of
practice, then this same
documentation procedure would
be appropriate within an
electronic patient chart.
REVIEWED BY
(TASKFORCE MEMBER)
Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove
Jim Cato
If documentation contains
information that must be verified
and co-signed by licensed
personnel, then appropriate
means for electronic signature
must be configured within the
electronic patient chart.
There are often attempts to
further restrict documentation
practices by non-licensed
personnel that is within scope of
practice by creating electronic
co-signatures. However, unless
there is a pressing reason to
further restrict or monitor the
Page 16 of 28
DATA OR EVIDENCE?
REFERENCE/SOURCE
http://www.fhdeland.org
/Portals/27/docs/Stude
nt%20Nurse%20Privilg
es.pdf
DATE
Sept 25,
2009
Toolbox
Questions – Answers - References
REF #
KEYWORDS
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
DATA OR EVIDENCE?
REFERENCE/SOURCE
documentation of non-licenses
personnel, the creation of
additional co-signature
processes creates an additional
burden of documentation for
licenses and non-licensed
personnel as well.
Regular audits of compliance
would be recommended, as
would audits for all processes
transferred to an electronic
documentation environment.
Examples of non-licensed
personnel:
 Nursing assistants/patient
care techs
 Therapy assistants
 Students
 Interns
 Unit secretaries
 Any role that documents
under the authority of a
licensed healthcare provider
19
What is
current
practice
related to
managing
clinical
students’
access to
clinical
documentatio
CARING
It seems that typically, prior to the
beginning of each semester, the
instructor contacts the IT department
to assign user names and passwords to
the students. The access administrator
receives a list of students who will
need information from or be entering
information into the patients electronic
medical record then assigns usernames
Page 17 of 28
DATE
Toolbox
Questions – Answers - References
REF #
KEYWORDS
QUESTIONS
n systems?
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
and passwords to the instructor. This
access typically has an expiration
based upon the end of the clinical
course. It is apparently a lot of work
to manage all the different clinical
students who train in the hospital so
some hospitals are assigning username
and passwords for the entire time the
student is enrolled in their respective
nursing school, medical school, rt, pt,
ot, etc. Some hospitals give nursing
students full security rights as they
would have as registered nurses while
others restrict their security rights to a
student nurse status.
Since the primary RN is ultimately
responsible for the evaluation of and
documentation for the patient it must
be the primary RN who co-signs the
medical record data as true and correct
(there are numerous ways to do this
and it typically is dictated by policy).
The instructor is not able to follow
every student into every room and
watch their every action thus
confirming that what is charted is true
and accurate.
DATA OR EVIDENCE?
Data
The ever more careful scrutiny of the
patient’s medical record creates
additional opportunities and
challenges with documentation,
especially when nursing students and
faculty are involved in providing
elements of nursing care. The
specifics of documentation policies
need to be developed within each
institution. Some points to consider
Page 18 of 28
REFERENCE/SOURCE
CARING
DATE
9-11-09
Toolbox
Questions – Answers - References
REF #
KEYWORDS
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
include:
♦ As a novice practitioner, a student
nurse's observations are subject to
careful review. A licensed nurse
needs to be aware of what the student
charted. The facility nursing staff is
ultimately responsible for reassessment if documentation
is in question.
♦ The patient record must provide for
traceability of care givers. This may
become especially challenging when
several schools of nursing utilize the
same facility and a caregiver only
identified as “SN” could come from one
of several schools. It is suggested
that as a minimum, students document
their name, student status and school
if more than one school uses the
facility. For example a student could
sign the record "Susan J.Nurse, SN,
Worlds Best College"
♦ The term “co-sign” is subject to
misinterpretation. Documentation must
clearly reflect if a “co-signer” is
verifying the accuracy of students’
charting or only verifying that they
have
reviewed the charting.
♦ A "co-signer" should not change the
original student entry unless the record
reflects that the change was made by
another party.
♦ If the facility policy requires
documentation that the student
charting was reviewed suggested
formats for charting may include:
• A faculty member signs the record
Page 19 of 28
DATA OR EVIDENCE?
REFERENCE/SOURCE
DATE
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QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
"WB Teacher, RN, MSN (oversight
signature)"
• A staff nurse signs "Charting
reviewed by WB Nurse, RN, MSN"
(http://drl.wi.gov/boards/nur/pap/pap1
8.pdf)
Students have an log in number for the
school that is different then their
employee number. Their log in ID gives
them more of a limited access then it
would if they were a nurse on the
floor. There is no co-signature
requirement for students’ assessments
that are documented in the computers.
The instructors review the
documentation that the students put
into the computer charting, however
we feel that to co-sign the students’
documentation would mean that we –
the instructors - have done that
assessment on that patient and often
that is not the case. Our clinical
instructors have up to 8 students and
they may have up to three patients.
We could not possibly do all of those
assessment plus give medications and
oversee new skills. We do co-sign
medication administration because we
are with them when they give
medications to their patients.
20
How is the
future state
included in
Page 20 of 28
DATA OR EVIDENCE?
REFERENCE/SOURCE
DATE
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21
KEYWORDS
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
the planning
and execution
of current
implementatio
ns or
enhancement
s? How are
technology
decisions
analyzed that
may
negatively
impact future
enhancement
s/building?
How are
decisions
made when
an urgent
need is
addressed in a
future
enhancement
that is not an
organizational
priority? What
is the current
best practice
window for
future
technology
planning?
What is
current
practice for
training staff.
What is the
current
practice for
Page 21 of 28
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DATE
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22
Portia
23
Jim
24
25
26
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
training and
utilizing
SuperUsers?
How are
SuperUsers
best utilized
as a resource?
What QA is
necessary for
electronic
systems?
Who should
do QA?
How is
standardizatio
n of practice
documentatio
n analyzed,
implemented
and
measured?
What is the
current state
of EHR use in
mental
health?
How are
ancillary
departments
trained to use
the EHR?
What is the
best practice
for use of
computer
protective
equipment
such as
Page 22 of 28
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REFERENCE/SOURCE
DATE
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REF #
27
KEYWORDS
Change
management
Change
QUESTIONS
keyboard
covers, and
computer
cleaning for
computers
used in
patient care
areas
What is the
best way to
plan and
manage
ongoing
change
between IT
and the
clinical areas?
ANSWER
Simple Answer: The best way to plan
and manage ongoing change between
IT and Clinical Areas is to have an IT
Adoption Methodology that promotes
change management along with a
supportive organizational culture.
Six key principles of effective,
sustainable change management
include: (See Graphic)
1. Need for Change – the
need for change (“Why?”) needs to be
clearly articulated, documented and
communicated. Without a need for
change there will not be any action
2. Shared Vision – often
times organizations function in
disparate, departmental silo’s. Having a
common/shared vision for where the
organization is headed is a key success
factor to effective Change
Management. Without a shared vision
there will be a “fast start that fizzles”
as other competing priorities take over.
3. Leadership Commitment
– the organizations entire leadership
team (not just certain individuals) must
be committed to the change. Anxiety
and frustration will result without a
unified leadership team to drive the
change.
4. Employee
REVIEWED BY
(TASKFORCE MEMBER)
Mark
DATA OR EVIDENCE?
Data
Page 23 of 28
REFERENCE/SOURCE
Multiple documents
DATE
9-4-09
Toolbox
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REF #
28
29
KEYWORDS
QUESTIONS
How is
emergency
access to the
HIS available?
ANSWER
Involvement/Commitment –
employees will be resistant to any
change that they feel has been forced
upon them. Early involvement of
employees and a demonstrated
commitment to change is essential
5. Integrated
Organizational Change – invariably
a change in one area of the
organization will trigger a change in
another. Integrating change across
departmental prevents a “siloed” view
of the change.
6. Performance Measures –
one of the most commonly overlooked
principles of effective change
management is documentation of
results through key performance
indicators. Without performance
measures in place there will be no
measurable results to sustain the
change.
For staff members, such as those from
Organ Procurement provided 2/47?
Identify staff who may be using the
system.
Preferred: Create logins for all agency
staff members.
Create one ID for each agency and
require a member to call the help desk,
where the date/time/name of the staff
member is recorded prior to issuing a
password. The password expires in a
defined time frame.
REVIEWED BY
(TASKFORCE MEMBER)
Melissa Barthold
Brenda Kulhanke
Trish Gallagher
Lisa Bove
how you
manage sound
on computers in
your hospital
DATA OR EVIDENCE?
REFERENCE/SOURCE
data
8-14-09
CARING list
Page 24 of 28
DATE
8-18-09
Toolbox
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REF #
30
KEYWORDS
CPOE
Order sets
Orders
QUESTIONS
setting. We are
having
discussions
about enabling
sound on select
devices where
possible for
nursing and
patient
education
(products like
Elsevier, etc).
How do your
hospitals handle
staff and patient
education? Do
you have
sound-enabled
devices at
certain
locations? If so,
how is your
patient
education
material
approved? Do
you have sound
at devices in
nursing stations
How are CPOE
order sets
best created?
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
Like most things in our increasingly
complex lives - one size doesn’t fit all
for CPOE implementation. There are
significant differences between critical
access hospitals vs regional hospitals
vs tertiary care facilities. Vertically
integrated systems have different
issues than do horizontal systems.
Below, I provide some
recommendations:
DATA OR EVIDENCE?
Data
Page 25 of 28
REFERENCE/SOURCE
Caring List
DATE
8-7-09
Toolbox
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REF #
KEYWORDS
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
1) Situational Awareness theory says
that the more you automate a process
- the less aware you become of the
process being automated. There can
be an increased incidence of providers
becoming reliant on the orderset to
guide their decision making verses
facilitating their decision making. Make
sure your ordersets are clear,
unambiguous and provide sufficient
ability for choice - without making it
too broad or too restrictive.
2) Study, study, study. Make sure you
understand how the organization and
all its parts work - and why. The more
you know - the more you can produce
competent tools and drive change.
3) Standardize, standardize,
standardize. Use a style guide that
defines what words mean, where
orders are found, in what order they
appear, how they are name etc.
Ordersets should be predictable - so
that regardless of the clinical situation,
providers can order safely and
efficiently.
4) Know the technology - what it can
do and can not do.
5) Test, test, test. Do exhaustive
testing with complicated and high-risk
workflows, like: blood transfusion,
titrations, pre-ops and oncalls,
sedation, lab based admins etc
Page 26 of 28
DATA OR EVIDENCE?
REFERENCE/SOURCE
DATE
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ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
DATA OR EVIDENCE?
REFERENCE/SOURCE
DATE
6) Ordersets and CPOE isnt just about
physicians! The order/orderset must
meet physician workflow AND the
departments that complete them.
31
CPOE
Nursing
Process
How are
telephone or
verbal orders
handled in a
CPOE
environment?
7) Confusing or error prone paper
based work flows make confusing and
error prone CPOE workflows. Fix policy
and workflow BEFORE going live with
CPOE.
No policy for telephone orders, the
mandatory use of CPOE is
in the orientation for the medical staff
as well as the nursing staff.
Connie Whittington
Our workflow for this is as follows:
1. All orders are in CPOE - no
exceptions
2. No verbal orders are taken for
CPOE unless in an emergent situation
with all hands needed on patient
3. no phone orders except in following
case:
a. RN calls with abnormal test result
or patient care need and
patient needs treatment related to this
b. MD is in transit from one place to
another and cannot access
computer - no more than 6 orders is
our guideline on this, just enough
to get patient care initiated. Note that
MD MUST remain on phone
while RN is entering the orders so that
they can reply to any alerts the RN
encounters when entering orders
c. if verbal orders are requested, we
ask that pathway orders or order sets
be accessed as orders are prechecked
and RN can read the orders off to MD
with rare/few changes
Page 27 of 28
Oct 13-09
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Page 28 of 28