Transcript slides for vch Horizon Expert Documentation

Horizon Expert Documentation
VUH Emergency Department
Learning Objectives

Identify workflow changes and processes that remain the
same (i.e. order tracker, trauma documentation)

Locate and document assessment and interventions for Adult ED patients

Demonstrate use of HED to record care under the Adult ED Hourly tab

Verbalize understanding of the changes in documentation and workflow
associated with new Falls/Safety HED build

For Admitted Patients, assign a plan of care in Starpanel, using a diagnosis
specific pathway if available, or if not using a generic pathway.

Identify standardized priority problems, patient oriented short term goals,
document an end of shift nursing summary and plan for next shift
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What’s changing, what’s not
Changing to HED
Not Changing
Triage process
X
Trauma patients
X
ED patient assessment
Use Adult ED tab instead of
StarPanel Nursing Assessment
Hourly documentation
Use Adult ED hourly tab
instead of StarPanel Nursing
Assessment
Med Administration
Planning and managing care
X
Priority Problems for Admitted
Patients under plan of care
tab in HED, save pathway to
StarPanel
Falls
assessment/documentation
Use Falls Risk/Safety
documentation in HED for
both ED and Admitted
patients. Will no longer be in
Social screening form.
Stroke & STEMI documentation
X
(paper form
now scanned)
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New Patient

Scenario:
Jane Doe, 58 y/o female with history of hepatitis,
HTN, and anxiety brought into ED by family for c/o
shortness of breath which has been going on for about a
week but worse today.
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Practice Scenario
Scenario:
 Patient brought to room C27 by wheelchair, ED property record
completed. Patient complains of shortness of breath with exertion and
anxiety
 Vital signs 98.1 oral, Pulse 101, RR 20, BP 170/95, O2 sats 88% on room air,
placed on 2L nasal cannula
 Airway is patent. Dyspnea on exertion. Lung sounds are CTA.
 Skin is warm, dry, and normal color. Mucous membranes are moist and
Cap refills is less than 3 seconds
 Heart rate is regular and pulses are 2+
 Eyes open spontaneously, verbal response is oriented, and motor response
obeys commands. Pupils are 4 mm and react briskly
 Complains of pleuritic pain. Rates as 4 on 0 to 10 scale. Pain is sharp
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Practice Scenario
Interventions:

18 gauge PIV inserted in right cephalic vein on first attempt

Urine and blood obtained and sent to lab

Patient sent to ultrasound via stretcher with transporter

Plan of care: MD evaluation, medications, observation,
diagnostic procedures & teaching
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Adult ED Hourly Tab
Scenario –
Patient comes back from ultrasound and a brief assessment is
done
 Respirations are even and nonlabored
 Skin is warm and dry
 Resting with eyes closed. Opens eyes to speech, verbal
response is oriented, opens eyes and follows commands.
 Patient complains of lower back pain and rates pain 9/10. MD
notified. Patient repositioned with pillows
 Dilaudid given for pain, documented in Order Tracker
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Learning Objectives

Identify workflow changes and processes that remain the
same (i.e. order tracker, trauma documentation)

Locate and document assessment and interventions for Adult ED patients

Demonstrate use of HED to record care under the Adult ED Hourly tab

Verbalize understanding of the changes in documentation and workflow
associated with new Falls/Safety HED build

For Admitted Patients, assign a plan of care in Starpanel, using a diagnosis
specific pathway if available, or if not using a generic pathway.

Identify standardized priority problems, patient oriented short term goals,
document an end of shift nursing summary and plan for next shift
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HED Changes with Safety/Falls
New Safety/Fall Risk documentation:
1. New evidence-based Morse Falls Scale
2. Updated Safety and falls assessment sections
3. Restraints documentation simplified
Restraints
4. New Education tab to capture specific topics and
caregiver(s) contact information
Falls/Safety Documentation now in
HED
ScenarioComplete Morse Fall risk screen:
•
•
•
•
•
•
Patient has not fallen in the last 3 months
Patient has multiple diagnoses
Uses a cane
Impaired gait
Has IV access
Knows own limitations/abilities
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Priority Problems Documentation in
HED
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Priority Problems for admitted/observation patients
WHY?

We all have different ways of describing or talking about
problems. You call it pain, I call it alteration in comfort

The decision was made to standardize how we talk about
nursing care. The Clinical Care Classification* (CCC) Saba
Model was selected
The Clinical Care Classification (CCC) System* is a
standardized, coded nursing terminology that identifies the
specific elements of nursing practice

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Priority Problems: What to Do & When
Admission
Beginning of
Shift
End of Shift
Transfer/
Discharge
• Select & Save Pathway (StarPanel )
• Document Phase (HED)
• Create 2-3 Priority Problems (HED)
• Review Pathway & Phase - change prn (HED)
• Document expected Short Term Goals for your shift (HED)
• Document Short Term Goal Status or outcome (HED)
• Document Nursing Summary & Plan & Priorities for next shift (HED)
• Start/End Priority Problems. Change Pathway &/or Phase prn.
• Document Short Term Goal & status (HED)
• Document Nursing Summary and Plan & Priorities in HED
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Admission
•Select & Save Pathway (StarPanel )
Choose the pathway that most closely reflects the expected
patient progression. Usually the reason for admission.
Specific pathways will have phases, goals and interventions
that are a better fit. The evidenced based pathways can
better guide care.

Medical Pathway – Pneumonia
1. Admission – Orders & interventions are aimed at achieving stabilization
(improving airway clearance by suctioning, O2, antibiotics, . . .)
2. Stabilization - achieving controlled symptoms (fluid excess control, med
mgmt for patients with chronic conditions)
3. Discharge – Ready for self-care; or care by another caregiver
Priority Problems: What to Do & When
Admission
Beginning of
Shift
End of Shift
Transfer/
Discharge
• Select & Save Pathway (StarPanel )
• Document Phase (HED)
• Create 2-3 Priority Problems (HED)
• Review Pathway & Phase - change prn (HED)
• Document expected Short Term Goals for your shift (HED)
• Document Short Term Goal Status or outcome (HED)
• Document Nursing Summary & Plan & Priorities for next shift (HED)
• Start/End Priority Problems. Change Pathway &/or Phase prn.
• Document Short Term Goal & status (HED)
• Document Nursing Summary and Plan & Priorities in HED
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Admission

•Document Pathway Phase (HED)
•Create 2 Priority Problems (HED)
Potential priority problems for Jane Doe:
1. Pain
2.Falls Risk
3.Airway Clearance
Definitions are
located under
“links” in HED.
Goals should be patient
specific and measurable
Such as
“Pain less than 4 on a
scale of 0-10”
Priority Problems: What to Do & When
Admission
Beginning of
Shift
End of Shift
Transfer/
Discharge
• Select & Save Pathway (StarPanel )
• Document Phase (HED)
• Create 2-3 Priority Problems (HED)
• Review Pathway & Phase - change prn (HED)
• Document expected Short Term Goals for your shift (HED)
• Document Short Term Goal Status or outcome (HED)
• Document Nursing Summary & Plan & Priorities for next shift (HED)
• Start/End Priority Problems. Change Pathway &/or Phase prn.
• Document Short Term Goal & status (HED)
• Document Nursing Summary and Plan & Priorities in HED
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Priority Problems: What to Do & When
Admission
Beginning of
Shift
End of Shift
Transfer/
Discharge
• Select & Save Pathway (StarPanel )
• Document Phase (HED)
• Create 2-3 Priority Problems (HED)
• Review Pathway & Phase - change prn (HED)
• Document expected Short Term Goals for your shift (HED)
• Document Short Term Goal Status or outcome (HED)
• Document Nursing Summary & Plan & Priorities for next shift (HED)
• Start/End Priority Problems. Change Pathway &/or Phase prn.
• Document Short Term Goal & status (HED)
• Document Nursing Summary and Plan & Priorities in HED
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Nursing Summary

Chart a brief synopsis of your shift before Shift change

Include major clinical events & information

For oncoming RN but does not replace face-to-face report

Prints on OPC as reference for nurse during shift
Plan and Priorities for Next Shift
 Your recommended plan and priorities for the oncoming nurse to address
 Think of it as a “to do” list for the next RN
 Keep it brief-240 character limit
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