OBJECTIVES: HED Nursing Documentation

1. OBJECTIVES: HED Nursing Documentation Document Interventions, Assessments Set Preferences & Create Assignment View Confirming Med Orders Commit to use HED system safety checks V: training/nurse resident2012

2. GENERAL PRINCIPLES OF ASSESSMENTS Beginning of shift or change level of care Items in ALL CAPS on gray bar charted each shift Line Manage charted each shift Vanderbilt charts to Standards & only denotes variances V: training/nurse resident2012

3. Nursing Summary • Brief synopsis of your shift before Shift change • Include major clinical events & information • For oncoming RN..does not replace face-to-face report • Prints on OPC as reference for nurse during shift Temp controlled with Tylenol. No further nausea. O2 sats improved on nasal cannula. V: training/nurse resident2012

4. OBJECTIVES: HEO and StarPanel • Explore StarPanel.. EMR • Look up test results and documents • Complete Admission History form • Assign a Pathway (Plan of Care) • Enter orders in HEO/Wiz… CPOE • Enter Nursing Orders for New Admission V: training/nurse resident2012

5. 3 Sections of Admission Data V: training/nurse resident2012

6. Example: Flu Immunization Screening V: training/nurse resident2012

7. Duplicate Name alert Inpatient Admission Observation Admission (short term stay) Patient has discharge orders Pre-Orders entered by Provider for Chg Nurse or MR to playback today HEO/Wiz Census Legend P V: training/nurse resident2012

8. Processing of Orders • Orders & Reqs print to Medical Receptionist (MR) and placed in unit appropriate area • MR: Notifies RN of STAT Orders and Labs • MR: Notifies Department of Other Tests • RN: Acknowledges Orders online Emergency Departments: Order do NOT print. Lab Requisitions generate to printer closest to pt’s room V: training/nurse resident2012

9. Steps to Acknowledge Orders V: training/nurse resident2012