Nursing Documentation Re-Design
FAQ: How can I view Inpatient Nursing documentation in StarPanel? What data has changed?
Most of the changes to Nursing Documentation will not impact team views of key nursing data. The work focused on
standardizing and streamlining documentation (Peds and Adults). It should effectively communicate the “patient story”
and meet regulatory requirements. For the Sept 15 pilot release on pediatrics 8A/8B/8C and adult 8N/8S:
 No change
o No changes to trended numeric data (Vital Signs, I&O) and devices (Vents, VAD, etc.)
o No new changes to the Nursing admission history
o No changes to current practice and/or policies (what & how often) – but changes to documentation
 Modified charting by exception by Care Category (Neuro, Pain, Activity/Musculoskeletal, Psych, etc.) using WNL,
WEL, OEL, or a specific problem. Definitions:
HED View
o
o
o
o
WNL – Within normal limits. Meets standard, published criteria for
developmental age. WNL requires no further documentation except: RASS SCORE,
BRADEN (Pressure Ulcer Risk), and FALL RISK STATUS are required q shift
WEL – Within expected limits. Doesn’t meet criteria for WNL, but is normal or a
new normal for the patient. WEL requires x1 documentation of the patients
baseline (Musculoskeletal = WEL Amputee x 10yrs).
OEL – Outside expected limits - Does not meet criteria for WNL, WEL or Problem
(see definition). OEL level requires supportive findings and focused re-assessment
(RASS=1). Only abnormal findings are charted unless part of Risk Scale criteria (i.e.
Glascow Coma Scale).
Nursing Problems –A nursing problem is a significant focus of the nursing plan of care (e.g. Incision, Pressure
Ulcer, Confusion, CO alt, Violence, etc.). Problem requires supportive findings, goals and focused reassessment. Those with a significance flag (red) are shift priority problems.
 Documenting re-assessment “unchanged” (within the nurse’s shift) if there was no change in the patient condition.
This should allow condition changes to standout. Example, for q1h neuro-vascular checks – you would see all the
initial values and then “unchanged” q1h documented if no changes.
 Simplified interventions and patient education
 Care Plan changes
o Nursing Summary & Plan Priorities & Goal status are now Response to Care/Recommendations
o Focus on Discharge Readiness
 New StarPanel views (see attachments):
o Updated plan of care in OPC, Team Summary, and Integrated Presence;
o 3 Customizable Flowsheets: NSG_DATA+, NSG_CARE, NSG_PLAN
Updated: 3/19/2016 10:31 PM by Ariosto
Nursing Documentation Re-Design
Documentation Reflects Standards of Care
Baseline Assessment: On admission, establish a baseline against which to evaluate changes in patient physiological,
functional, developmental and behavioral health status. This includes pertinent medical, procedural and medication
history as well as home medical equipment, therapies and duration of therapy. Initiate high risk screening as
warranted/ required (influenza, sleep apnea, nutrition, abuse, pregnancy risk, lactation). Special populations require
additional screening (e.g. OB, neonate, psych). Note significant conditions and devices present on admission (e.g.
pressure ulcer, CVC) not already noted. Any cultural/religious consideration should be noted if relevant. Initiate
individualized care plan.
Shift/Assigned Caregiver Change Assessment: Assessments (including devices) shall be performed at a minimum, every
shift, with change in level of care or more often if instability or risk exist for all inpatients (adult, peds, acute, critical).
Additional assessments may be required.
Focused Assessment: Abnormal, unexpected findings or patients with significant risk of problems may merit further
assessment and intervention. Interventions include monitoring, treatment as ordered and those within scope of
practice, patient and family education referrals/escalation as warranted. Findings of risk will dictate the frequency of
the focused assessment.
Devices: Any line, tube, appliance, equipment connected to the patient for monitoring or treatment of illness or injury.
Devices are assessed per policy or practice guidelines including (1) patient’s response to current level of device support;
(2) setting check; and (3) proper functioning of equipment.
Updated: 3/19/2016 10:31 PM by Ariosto
Nursing Documentation Re-Design
Exhibit A – New StarPanel Views
Available from FLOWS & Actions Menu (after there is 24 hrs of documentation)
1
FLOWSHEET NAME
NSG_DATA+
2
NSG_CARE
3
NSG_PLAN
NURSING CONTENT
Trendable Data:
 All Vital signs (non-invasive, invasive)
 Pain# and Scale
 Height, Length, Weight
 Risk Section: Total Score/Status: Braden, Fall, PEWS, GCS, etc.
 I&O, IV Drips
 Device data (Vents, ICP, VAD, etc.)
 Assessments & Supporting S&S
 Interventions
 Excludes VS,I&O,IV Drips, Device data
 RESPONSE TO CARE/RECOMMENDATIONS
 Communication/Event Note(s)
 Discharge Plan of Care Reviewed
 DISCHARGE READINESS
 Discharge Problems Needing Follow-up
 Goals
 ASSESSMENT/PROBLEMS
 Care Contacts
 EDUCATION & ENGAGEMENT
+ = includes some respiratory therapy data
Other Documentation: (4) Admin Hx (StarForm), (5) Vascular Access (graph), (6) Wounds/Drains/Tubes (graph) use the
current StarPanel Views. These 6 views represent all of HED documentation and key Starforms.
Updated: 3/19/2016 10:31 PM by Ariosto
Nursing Documentation Re-Design
You can customize to show only the fields that are important to your view, or capture all that is documented
1. Nursing Data+
 Trendable Data:
 All Vital signs (non-invasive, invasive)
 Pain# and Scale
 Height, Length, Weight
 Risk Section: Total Score/Status: Braden, Fall, PEWS, GCS, etc..
 I&O, IV Drips
 Device data (Vents, ICP, VAD, etc.)
2. Nursing Care
 Assessments & Supporting S&S
 Interventions
 Excludes VS,I&O,IV Drips, Device data
3. Nursing Plan
 RESPONSE TO CARE/RECOMMENDATIONS, Communication/Event Note(s)
 DISCHARGE READINESS & Discharge Problems Needing Follow-up
 ASSESSMENT/PROBLEMS & Goals
 EDUCATION & ENGAGEMENT + Care Contacts
Updated: 3/19/2016 10:31 PM by Ariosto
Nursing Documentation Re-Design
Exhibit B - Care Plan changes in OPC, Team Summary, and Integrated Presence
CURRENT CARE PLAN VIEW in OPC, Team Summary, Integrated Presence
NEW CARE PLAN
No Pathway and Phase
Nursing Plan (last 24hr HED)
Response to Care/Recommendations (date/time):
Replaces Nursing Summary, Plan Priorities, Goal Status (see below)
Communication/Event Note(s) (date/time):
All significant communications or events narrated here
Goals: (date/time)
Replaces short term goals
Priority Problems: Vent wean impairment; Restraint injury risk Other Problems:
DISCHARGE READINESS: Resource Constraints, Knowledge deficit, Non-Adherent…..
Discharge problems needing follow-up: Unable to afford meds (Joe Smith, MSW is working on this)
Updated: 3/19/2016 10:31 PM by Ariosto
Nursing Documentation Re-Design
Exhibit C - WNL DEFINITIONS
FAQ – What is our standards of care for assessments and WNL documentation?
ADM/BASELINE HISTORY +
Pain
Pain screen
Neuro
Hx Neurologic condition or
procedure & meds Mental
status hx -Sensory
Assessment: Baseline visual &
auditory function
Cardiac
Hx Cardiac condition
procedure or devices
Vascular/Perfusion
Hx peripheral vascular
disease, edema or
pulselessness in extremity
Respiratory
Hx respiratory condition
Screen: Flu, Sleep apnea
Home resp devices (CPAP,
vent, trach)
Gastrointestinal
Hx GI condition or procedure
Bowel routine
Urinary/Renal
Hx Urinary/Renal condition or
procedure; Bladder routine
Reproductive
Hx Pregnancy, LMP; Lactation,
Pregnscreen
Skin
Hx of skin conditions
Presence of pressure ulcer on
admission
Activity/Musculoskeletal
Hx Musculoskeletal conditions
or procedures
Need for patient assistive
devices and transfer assistive
devices
STANDARD ASSESSMENT
ALL PTS EVERY SHIFT
Assessment
Pain using age/situation
appropriate assessment
Assessment
Mental status,
level of consciousness,
basic motor function
Speech
Assessment
BP, Heart rate,
rhythm,
heart sounds
Assessment
Capillary refill, edema,
peripheral pulses
Assessment
Breathing pattern
& effort, breathsounds,
airway status, presence &
character of secretions
Assessment
Abdominal appearance,
bowel sounds,
bowel movement
Assessment
Adequate urinary output &
character.
Assessment
Assessment
Skin color, appearance,
condition and pressure ulcer
risk screen.
I
Assessment
Activity level,
mobility,
positioning
DOCUMENT ASSESSMENT WNL IF:
No WNL defined – use pain scale
=WNL if
= Alert & Calm, Oriented x4 (person, place, time, situation);
Developmentally appropriate speech; No gross motor deficits
=WNL if
= BP within expected range for age; Expected heart rate for age;
Regular rhythm; No abnormal hearts sounds
=WNL if
= Extremities warm with absence of pallor and cyanosis
Equal palpable peripheral pulses (2-3+); Capillary refill time less than
2 to 3 seconds; Absence of edema
=WNL if
= Expected rate and depth of breathing for age
Absence of dyspnea; Clear, no adventitious breath sounds
Oximetry results within baseline range; Arterial blood gas values
within baseline range ; Minimal cough; Minimal clear secretions;
Patent airway;
=WNL if
= Bowel movements within own usual pattern and consistency
without difficulty; Normal bowel sounds present in all quadrants;
Abdomen soft, non-distended, non-tender
=WNL if
= Urinary Continence – age appropriate; Voids without difficulty and
at normal intervals; Adequate urinary output
No distention; Clear straw to amber colored urine
=WNL if
tbd
=WNL if
= Healthy oral mucous membrane ; Absence of pallor or cyanosis;
Absence of redness and irritation (incl IV site checks); No skin
breakdown; Braden PU risk score >16
=WNL if
= No or minimal mobility limitations (not on bedrest/chairfast
restrictions); Uses usual assistive devices safely (WEL). No c/o severe
fatigue, generalized weakness or sleep deprivation
Updated: 3/19/2016 10:31 PM by Ariosto
Nursing Documentation Re-Design
Nutrition
Hx Nutritional conditions
Weight Hx
Devices (dentures,)
Lactation
Fluid & Electrolytes
Hx of fluid or electrolyte
imbalance
Safety/Falls
Hx of Behavioral Health
problems, Hx of substance
use/abuse (tobacco, alcohol,
drugs),Hx of injury or falls,
Abuse screen, Hx of violence
to self / others
Medications
Medication list
Self-Care/ADL
ADL
Infection/Metabolic
Hx thermoregulatory, Immune
or Endocrine disorders.
Allergy Hx – drug , food,
environment
Psycho-Social
Hx Behavioral health
condition. Hx of nonadherence to prescribed
medical regimen; use of
community services
Cultural considerations.
Advance directives,
Assessment
Nutritional appearance, diet,
general food intake pattern &
diet tolerance
=WNL if
Excellent or Adequate Nutrition (Braden); Not NPO; Weight does not
require intervention such as- nutritional restriction or supplementals;
Normal BUN and serum albumin.
Assessment
=WNL if
Electrolytes within normal range
Balanced I&O
Assessment
Evaluate risk for injury from
environment, equipment, and
patient condition
=WNL if
Low fall risk score (Morse)
No signs of tobacco, alcohol, or illicit drug use
No aggressive or self-injurious or impulsive behavior
Assessment
Evaluate medication
indications, patient response
and risks
Assessment
Participation/ability for selfcare
Assessment
Basic vital signs
glucose levels
=WNL if
No high risk meds, chemo, or radiation (per policy)
No more than 6 scheduled meds
Assessment
Evaluate patient and support
systems, mood, behavior,
coping, adherence to plan,
engagement and ability to
participate in care as age and
developmentally appropriate.
=WNL if
Participating in plan of care as prescribed
Appears to be coping with condition and care
No evidence of dysfunctional family and support systems
No behavioral health concerns affecting plan of care.
=WNL if
Is willing and able to participate in self-care activities such as feeding,
grooming, hygiene and toileting.
=WNL if
No S&S of Infection ; Normothermic
No glucose, endocrine, or immunologic disorder
Updated: 3/19/2016 10:31 PM by Ariosto