Toolbox
Questions – Answers - References
REF #
1
QUESTIONS
What issues should be
considered related to ‘copy
forward’?
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
Copy forward may be used very carefully. Clear policies covering
this use should be available.
When making this decision, the following should be considered:
Melissa Barthold
Lisa Bove
Jim Cato
Brenda Kulhanek
Stakeholders in the decision: CNO’s, Practice Councils, Risk
Management, Legal department.
DATA OR
EVIDENCE?
Evidence and
dataSurvey
Results:
(date)
NUMBER OF
RESPONSES
REFERENCE/SOURCE
http://journal.ahima.org/2
008/06/04/anappropriate-use-of-copyforward-with-a-caveat/
Discussion on CARING list
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?
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?
2
3
4
5
How is the electronic
signature defined?
Should physiologic data
imported from monitors be
validated before data is it
stored in the EMR?
What is the process for
defining what data should be
included in documentation?
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.
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.
When making this decision, the following should be considered:
Build documentation that reflects best practice and standards’
What type of format should
be used to indicate errors or
changed documentation?
Page 1 of 5
Brenda Kulhanek
Lisa Bove
Melissa Barthold
Portia Towns
DataCARING llist
Discussion on CARING list
DATE
April,
2009
Toolbox
Questions – Answers - References
REF #
6
QUESTIONS
“Error explanations– changes
– how much should be in
strikethrough format? Or
should it be in that format?”
What are the best devices
and device configurations
that support nursing
workflow?
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
DATA OR
EVIDENCE?
NUMBER OF
RESPONSES
REFERENCE/SOURCE
When making this decision, the following should be considered:
Do you support point of care (real-time at the patient’s side)
charting?
What applications are currently in use and what are planned?
7
8
9
10
11
12
What are current practices
related to use and storage of
mobile documentation
devices such as rolling
computer carts?
Are mobile carts (COW’s,
WOW,s, etc.) allowed in the
hallway?
What is the best practice for
maintaining the power
supply on mobile devices?
How is the appropriate
number of documentation
devices determined?
How is ‘timeliness of
charting’ defined?” How is
this affected by the
contraints of documentation
technology?
Are ‘default’ answers in
forms permitted? How is the
scope of default answers
determined?
What processes are used to
document during a computer
If you are using electronic medication records with bar coding, do
you need a place to store individual medications?
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 available for parking the devices to maintain power?
Place outlets/network drops at an ergonomic height.
When making this decision, the following should be considered:
Is timeliness defined in other applications?
When making this decision, the following should be considered:
Do you allow defaults on paper forms or in other applications?
Page 2 of 5
Brenda Kulhanek
Lisa Bove
Melissa Barthold
Portia Towns
Data
CARING list July 2009
DATE
Toolbox
Questions – Answers - References
REF #
13
14
15
16
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
downtime?
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?
What is current practice for
communication of downtimes
to clinical areas?
What is current practice for
communication of systemrelated changes,
enhancements or
downtimes?
Does charting-by-exception
support best practice? Is it
legally defensible?
DATA OR
EVIDENCE?
NUMBER OF
RESPONSES
REFERENCE/SOURCE
"Ladies & gentlemen
of the jury, I present...
the nursing
documentation".Full
Text Available
(includes abstract);
Austin S; Nursing,
2006 Jan; 36 (1): 5664 (journal article case study, CEU,
exam questions)
ISSN: 0360-4039
PMID: 16395021
CINAHL AN:
Page 3 of 5
DATE
Toolbox
Questions – Answers - References
REF #
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
DATA OR
EVIDENCE?
NUMBER OF
RESPONSES
REFERENCE/SOURCE
2009089387
17
18
19
20
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 documentation by nonlicensed staff is permitted in
the EMR? What is current
practice related to RN cosignature of documentation
entered by non-licensed
staff? Is the practice or
policy enforced through
technology or policy alone?
What is current practice
related to managing clinical
students’ access to clinical
documentation systems?
How is the future state
included in the planning and
execution of current
implementations or
enhancements? How are
technology decisions
analyzed that may negatively
impact future
enhancements/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
Page 4 of 5
DATE
Toolbox
Questions – Answers - References
REF #
21
22
23
24
25
26
27
QUESTIONS
ANSWER
REVIEWED BY
(TASKFORCE MEMBER)
window for future
technology planning?
What is current practice for
training staff. What is the
current practice for 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 standardization of
practice 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 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?
28
29
30
31
Page 5 of 5
DATA OR
EVIDENCE?
NUMBER OF
RESPONSES
REFERENCE/SOURCE
DATE