Horizon Expert Documentation VUH Emergency Department

1. Horizon Expert DocumentationVUH Emergency Department

2. 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 • Verbalize understanding of the changes in documentation and workflow associated with new Falls/Safety HED build

3. What’s changing, what’s not

4. 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.

5. 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

6. 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

7. 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

8. 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 • Verbalize understanding of the changes in documentation and workflow associated with new Falls/Safety HED build

9. 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 4. New Education tab to capture specific topics and caregiver(s) contact information Morse Scale Restraints Education

10. 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

11. Priority Problems Documentation in HED v:training/neo/rn/2011/day1

12. Priority Problems for admitted/observation patientsWHY? • 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

13. Priority Problems: What to Do & When v:training/neo/rn/2011/day1

14. Select & Save Pathway (StarPanel ) Admission 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 • Admission – Orders & interventions are aimed at achieving stabilization (improving airway clearance by suctioning, O2, antibiotics, . . .) • Stabilization - achieving controlled symptoms (fluid excess control, med mgmt for patients with chronic conditions) • Discharge – Ready for self-care; or care by another caregiver

15. Priority Problems: What to Do & When v:training/neo/rn/2011/day1

16. Document Pathway Phase (HED) • Create 2 Priority Problems (HED) Admission Goals should be patient specific and measurable Such as “Pain less than 4 on a scale of 0-10” Definitions are located under “links” in HED. • Potential priority problems for Jane Doe: 1. Pain • Falls Risk • Airway Clearance

17. Priority Problems: What to Do & When v:training/neo/rn/2011/day1

18. Priority Problems: What to Do & When v:training/neo/rn/2011/day1

19. 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 v:training/neo/rn/2011/day1