Transcript Clinical Documentation in SMS

Clinical Documentation in
SMS
Discharge Instructions
Why Clinical Documentation?
•On line Nurses Notes
•More legible notes
•Easy multi-disciplinary access
•Less redundancy in charting
Roll-out of
Discharge Instructions
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Pilot floors – 5E and 7N
Roll-out to other nursing floors following pilots
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Schedule on Intranet (Nurses/Clin Doc)
Education – (1-hr class) prior to roll-out
Support – 11am-7pm during first week floor is live
with the system
Rationale for D/C instructions first - no problems
between floors
Open-ended update – Update button allows for early
initiation of D/C instructions
Class format
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Review d/c instruction screens
Sign into SMS Test system
Choose patient from 8North
Do d/c instructions from samples
Print out instructions
Fill out evaluation
D/C Instructions Screen 1
D/C Instructions Screen 2
D/C Instructions Screen 3
D/C Instructions Screen 4
Important things to remember
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Update– use if more info to be added
later
Complete – use if you are the last person
to do the instructions and will be giving
the instructions to the patient
Avoid using military time
Use language patient will understand
(printout will translate med frequency into
patient language)
Names of doctors and medications will
default to caps (for pt readability)
Important Things to Remember
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Paper Form of D/C instructions – after go-live,
should be used only during down time
Trained staff – may use computerized D/C
Instructions on non-live floor only on day of
discharge
No pro-active prep of computerized D/C instructions
until floor phased in
If Complete chosen in error, select Add
to/Change…, highlight the completed assessment,
click the Change button, then the Update/Pending
button.
More Important Things to
Remember
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At bottom of medications screen – use comments area for
general comments
Tapering doses of medications – make them the last med(s)
on list for nicer print-out
15 minute log-out time – to prevent auto-logout, click on
Continue or Previous button to ensure 15 more minutes
RN must co-sign signature page for LPN – this page requires
a signature, as it becomes a permanent part of the medical
record.
If pt is transferred to non-live floor and has D/C Inst started,
PRINT copy - send with pt so info can be added to paper form