Transcript Electronic Controlled Drug Record (eCDR) in

Electronic Controlled
Drug Record (eCDR)
in
eCDR Overview
Controlled Drug Record documentation will be
completed in HED instead of on the paper CDR.
•
Paper CDR will only be used for transfers into or out of areas
not using CDR in HED or during downtime.
• Epidural infusions will remain on paper CDR at this time.
• New CDR tab in HED.
VUH Towers
2/10/15
eCDR Timeline
2014-15
VCH 6A
1/20/15
SICU & 9S
9/15/14
Palliative Care
Pilot
8/12/14
Aug ‘14
Burn & PICU
Pilot
9/23/14
Sept ‘14
Jan ‘15
Feb ‘15
CCT, MCN
& 4E
2/17/15
VCH
2/24/15
Start Infusion
Don’t
forget to
Co-Sign!!
Drug Label
The drug concentration
to be entered in HED
can be found on the
medication label.
Locate priming volume
on packaging of IV
New Bag/Syringe
Don’t
forget to
Co-Sign!!
Charting Specifics
Stop Infusion
Annotate if Left to Count is not zero:
“Wasted amount measured &
witnessed by 2 RNs as per protocol”
End of Shift/
Handover Report
*When reporting to another area using HED CDR
During handover report the nurse should
chart volume at start and cosign.
Reminder: Clear pumps at the end of each shift or per unit standard
Co-Signing
RacfID is required to co-sign in real time.
What’s Changing
• Blank CDRs will no longer
be available in AcuDose
with meds. Call pharmacy
if a paper CDR is needed
• Documentation of all
requirements elements will
be under new CDR tab in
HED, including cosignature
• For areas, not using HED
CDR documentation, paper
CDR will be used in
handover
What’s NOT
Changing
• Assessment of
patient under
sedation or on pain
medications
• Documentation of
the following will still
take place in HED:
– IV Intake
– IV drip rates
When & Where to Cosign
• When
• Where
Starting/Ending new bag on unit – HED
Cosign in HED
Change in caregiver
Cosign in HED
End of Shift/Bedside Report
Cosign in HED
Transferring patient to unit using CDR
Cosign on CDR and annotate See CDR
Receiving patient from units using CDR
Transfer to area not
using HED CDR Tab
• If you receive a patient with a paper CDR, follow
the Start Infusion instructions using the CDR
amount as Amount at Start.
– Annotate “See HED for CDR documentation”
– Paper CDR should remain in the chart & be scanned into EMR
• If you transfer a patient to another area, you
must transcribe Left to Count from HED to the
CDR.
– Annotate “See HED for CDR documentation”
– Paper CDR should be given to the transfer unit
RacfID
Password Reset
If you do not know your RacfID or password, please call the Help Desk at
(3-HELP) to have your RacfID password reset prior to implementation.
If you want to have the same password for both your VUNetID ePassword and your RACF ID, follow these guidelines:





The password must contain exactly 8 characters
It must have at least one capital letter
It must have at least one number
It cannot have any special characters or be a part of your name, SSN, user ID, or date of birth.
Example: Coconut1
To reset your VunetID password click the following link: http://its.vanderbilt.edu/epassword/
VUH Tuesday 2/10/15
MCN, CCT & 4E Tuesday 2/17/15
System Support Staff will be providing 24/7 onsite support.
If you have questions or need assistance:
Call the Help Desk at 343-4357 (3-HELP)
Process for Controlled Drug Record Charting in HED CDR Tab
• Drug, dose, concentration, start volume, primed volume entered. Co-sign required.
Start
New Bag,
Rate Change,
Hold
• Correct patient, drug, dose, concentration, infusion rate & pump settings verified by 2. Co-sign
required.
• Amount infused (dose, intake, volume @ start, volume infused). No co-signature needed.
Q4h
Handover/
Change of
Shift
• Correct patient, drug, dose, concentration, infusion rate & pump settings verified. Pump cleared q12 h.
Co-sign required
• Drug status: “stopped”; volume @ start, volume wasted. Co-sign required.
End
Transfer
from/ to
Paper CDR
area
• Sending to paper CDR unit: transcribe “left to count” from HED to CDR & send paper CDR to receiving
unit. Note “See HED for CDR documentation” on CDR.
• Receiving paper CDR: follow “Start” instructions above; place paper CDR in paper chart.
Note “See HED for CDR documentation” on CDR.