Charting a New Course for Patient Documentation

1. Charting a New Course for Patient Documentation Super User Training

2. What You Will Learn Today Upon completion of training, the learner will demonstrate ability to: 1. Share the vision for the changes in nursing documentation 2. Identify at least 2 “Myths” that have been barriers to documentation reduction in the past and verbalize an effective response to both 3. Complete a documentation scenario without assistance 4. Verbalize 3 expectations of a Super User during unit implementation 5. Identify 5 resources available to all staff to support transition to the new documentation processes 6. Demonstrate 3 techniques most likely to be effective in promoting peer adoption of the changes.

3. THANK YOU The Super user role is vital to implementation of this change!

4. Charting A New Course for Patient Documentation Why chart a new course? Nurses need more time with their patients and to spend less time writing about what they are doing with their patients! PUT VALUE BACK INTO WHAT NURSES DOCUMENT With revisions, need to assure that everything that the nurse is documenting is valuable and contributes to the patient story and informs the care you and others give.

5. FOCUS Targeted design for the proficient, ethical nurse Not designed to be everything to everyone

6. STOP!!! • Stop documenting MOST normal values • Stop charting data no one looks at or uses • Stop duplicate documentation • Stop transcribing data from devices

8. Myth Busters

9. “If it’s not charted, it’s not done.” “Quantity of documentation = quality of care I provide” “I have to chart this because it’s required by … “ [Joint Commission, Hospital Policy, Risk Management, etc.]

10. We are reducing documentation in order to increase nurse to patient ratios or make other staffing changes. NOT TRUE! No further changes are planned to the staffing models. Documentation reductions are needed to make the model work better.

11. Those making all these changes are out of touch with what really happens at the bedside- these changes will never work. NOT TRUE! Many levels of nursing were involved in developing the revisions.

12. . “Real Nurses” were involved

13. What is NOT changing: • Care Organizer & Admin-Rx • General format of HED screens and way to select items from drop down menus or typing annotations • Nursing Admission History still in StarPanel • Clinical Care Classification (CCC) standardized terminology for documentation of problems • Required documentation denoted by ALL CAPS • Concept of Priority Problems/ goals

14. Patient Scenario • Pt admitted with complaints of a deep and productive cough for 1 week with progressively worsening yellow phlegm. • Wheezes present in BLL • Patient is asthmatic • Admission dx is pneumonia • Pt reports hx of asymptomatic AFib X 5 yrs • Patient small stage 1 PU on left buttock • Hypoactive BS • You receive the pt from the ED with antibiotics infusing in r forearm 20 G PIV • Other than respiratory issues the patient healthy

15. The Nit and the Grit of the changes Sign on to CWS w/ your id Click HED train icon Use the training patient on your card

16. New Tabs & Order • In the training region you may see both the current tabs & new tabs. • In Live HED, the PLAN tab will load 1st • Most of the new tabs are in ALL CAPS

17. Old VS New Tabs • Most of the new tabs will be in ALL CAPS but there are some existing tabs that are in ALL CAPS too ( i.e. CRRT) that will continue to be used as we transition. • There are also some tabs that are used now that will transition over that are not in all caps – i.e. Blood transfusion, chemo, Pain/CDR. • On the chart menu, there will also be the tabs for the areas that are not being implemented in this first phase ( i.e. NICU, OB)

18. Pain Documentation In Live HED, you will see reduced fields for pain documentation: Reassessment of pain is documented with a new score Pain documentation requirements have NOT changed, there are just less fields to document on. Refer to Policy Tech for more details.

19. Pain Interventions Will not be found in the Assessment tab Can be found in Interventions, All Doc, Pain/CDR, or AdminRx. New options:

20. Learner Engagement In HED Live, you will see Learner Engagement (session)

21. Protocols Tab New Protocols Tab including CIWA, etc.

22. Nursing Documentation Guidelines Review

23. Tips for ALL DOC If you can’t find an item, go to ALL DOC & use the Add button to search • The following items can be found in ALL DOC: • Transfer & transport • Isolation Precautions (or in Interventions) • Co-Sign (for students) • Downtime • Use the “Add” button to search for items in All Doc

24. Discharge Discharge Plan of Care Reviewed, Discharge Readiness and Discharge Problems needing follow-up have been moved from the  Assessment/Problem section to the Plan of Care section on the PLAN Tab & the Education tab. A current shift assessment should be completed prior to discharge, problems needing follow-up should be identified and documented with a plan to address.

25. When to Document What…

26. Display of Data Currently, most of the documentation is displayed in a real time view. Some spend a lot of time adjusting times they document to be at the top of the hour so the data aligns in a single column, making viewing info easier. With the revisions, the displays of the data has been collapsed to facilitate easy viewing. Data displays in 1 hour increments • VS/I&O • Assessment • Interventions • Pain/CDR • Device • Protocols Displays in 12h increments • Plan • ALL DOCS Displays in 24h increments • Education Click Chart to see the actual Documentation Times

27. Shift to Shift Handovers Use the Plan tab to facilitate handovers. It should capture the patient story.

28. Training and Implementation

29. Transitioning from Old to New GO LIVE DAY Tech team will push the new tabs to HED “LIVE” by 0700 Day shift will begin using the new tabs To view previous charting, toggle back to the “old tabs” from the tabs drop down menu or via the chart option in the top tool bar

30. Role & Responsibility • At the Elbow Support to Nursing Staff ( answering ?s and coaching) • Review Documentation via chart audits and follow up with users for any issues • Report problems/Issues • Roll model completion of ALL 4 LMS modules and Unit Practice Scenario • Follow-up with staff assigned to you to encourage and track completion of LMS modules and Unit Practice • Communicate to Manager any concerns about readiness of staff assigned to you Expectations of a Super User during unit implementation:

31. Resources

32. Resource Resources available to all staff to support transition to the new documentation processes Hover Overs/ Links in HED (Krames)/ Mosby Nursing Documentation Policy Job Aide Super User Guidelines for Nursing Documentation Support Systems Support Nursing Education Website FAQ Debriefing sessions Colleagues on the documentation committee/ SSS /Educators Help Desk What Else???

33. Online Resources Click icon on desktop or link on VUMC webpage Type SSS in main VUMC webpage and select System Support Services to get our webpage.

34. Promoting Adoption TAKE CARE OF THE PATIENT, then worry about charting! Demonstrate 3 techniques most likely to be effective in promoting peer adoption of the changes. Timing Approach Follow-up

35. Timing Is Everything… Would you approach a nurse or staff member in the following situations? In the break room? At the accudose machine? Two nurses discussing the upcoming weekend? A care partner running with a crash cart? A nurse near a room with visibly upset family? A nurse providing care?

36. Approach Coach/ mentor – non punitive “ I am touching base with all RNs to see how charting is going with the new system. It’s a big change and I am here to help. What did you think? Did you have any questions or concerns. Then give feedback… I noticed “…..” Do not give a huge list of issues- prioritize It will take a lot of coaching and practice

37. Approach (cont.) • More Direct Phrases to add to your collection • “Can you tell me a time when I can come back?” • Check with charge nurse for best times to return considering typical unit workflow patterns

38. Follow up • Denote all ?s/Concerns and seek out answers • Prioritize • Investigate • Triage

39. What’s wrong with this picture?? Admission Assessment • Only chose 1-2 Priority Problems • Only set goals for those 1-2 priority problems • Chart ALL categories on admission • Annotate WEL on admission • Make sure there is supporting data for OEL • Is it WEL (baseline) or OEL?

40. What about “difficult” users

41. Strategies • Don'ts • Be comforting not confrontational. • “I know it’s hard and it takes more time right now.” • “I understand your frustration.” Do’s

42. Role & Responsibility • At the Elbow Support to Nursing Staff ( answering ?s and coaching) • Review Documentation via chart audits and follow up with users for any issues • Report problems/Issues • Roll model completion of ALL 4 LMS modules and Unit Practice Scenario • Follow-up with staff assigned to you to encourage and track completion of LMS modules and Unit Practice • Communicate to Manager any concerns about readiness of staff assigned to you Expectations of a Super User during unit implementation:

43. Repeat after me…. SUPPORT CREDO I am responsible for getting this fixed, and for documenting the problem and its solution. I understand that people are frustrated and angry, but I won’t take their anger personally. I will empathize with the frustration that my peers feel, and tell them that I understand and share their feelings. I will calm them down with my words and manner. I will not accept abuse. I will not blame the user.

45. Next Steps • Complete the LMS modules • Complete a Unit Practice ( on your own) • From your manager/educator, get list of staff you are coaching (approx 10) • Communicate to SSS any concerns or questions • PLAY in HED train