Physical Assessment Documentation Change Tutorial

1. Physical Assessment Documentation ChangeTutorial PowerChart—Clinical Documentation Summer 2008

2. Physical Assessment Documentation Change Objectives • Define rationale for changes; • Demonstrate how the changes to the physical assessment form support efficient and effective documentation; • Explain how to use the revised edema and skin integrity grids.

3. Rationale for the Change • The physical assessment form must capture positive and negative findings. • The form should make it easier for the nurse to identify changes in patient status. • These changes will support future system enhancements and the continued use of charting by exception (CBE).

4. Charting By Exception (CBE) • Charting by Exception is a streamlined format that is used to enable nurses to quickly and completely chart findings that match or deviate from “Defined Normal” assessment parameters.

5. Charting By Exception (CBE) • Each body system has a definition of “Defined Normal” located in the window (aka “Genview”) at the top of each body system form and/or section. • “WDL” (within defined limits) specifies the finding for each parameter that is considered normal. • Deviations from normal are documented using “WDL Except” and the exceptions must be specified.

6. Physical Assessment Form Changes: • All “defined normal” parameters default to “WDL.” • This implies that the parameters of the system that were opened, were assessed, and found to be within defined limits. • If nothing is changed and the form is signed, the “defined normal” parameters for the system will indicate WDL on the flowsheet.

7. Note each defined parameter defaults to “WDL”; also note that last charted value (LCV) will appear in the “Genview”.

8. If no changes are made to the default settings of “WDL” when the physical assessment is signed, it will indicate that all defined parameters have been assessed and have been found to be “WDL” of the defined normal of the body system that has been assessed.

9. Nursing Flowsheet: Note that all “WDL” parameters will post to the nursing flowsheet when documentation is signed.

10. Physical Assessment Form Changes (cont.): • “WDL Except” and “Additional Parameters” remain unchanged. • “Unable to Assess” has been added to each defined parameter in each body system; if selected, a reason “Unable to Assess” is required.

11. Selecting “Unable to Assess” will open the “Reason Unable to Assess.” (This is a required field and must be completed prior to signing the documentation).

12. The following slides will demonstrate documentation on the physical assessment related to the changes that are being implemented. Charting a Physical Assessment

13. Select “Neurological” to continue.

14. Note: All defined normals default to “WDL”.

15. If no changes are made to the default settings of “WDL” when the physical assessment is signed, it will indicate that all defined parameters have been assessed and have been found to be “WDL” of the defined normal of the body system that has been assessed.

16. Selecting “Unable to Assess” will open the “Reason Unable to Assess.” (This is a required field and must be completed prior to signing the documentation).

17. Selecting “WDL Except” will open additional conditional fields, which are required, to document assessment findings.

18. Note: “LOC” & “Gross Movement” were selected as “WDL Except.” These fields will turn white to allow documentation, and are required, prior to signing.

19. Note: If “WDL Except” is not selected, all remaining fields will remain “grey” or “dithered”; documentation can not occur in these fields.

20. Select “Cardiovascular” to continue.

21. “WDL” will be the default for each body system when the assessment section/form opens. Signing the form, indicates that all “Defined Normal” parameters have been assessed. Click on the “Back Arrow” to continue.

22. After documentation on the physical assessment form has been completed, sign the form. Click on the “Check Mark” now to sign and continue.

23. Selecting the “Nursing” Tab allows all disciplines to review documentation. Select “Neurological” from the navigator to continue.

24. Note that the “Reason Unable to Assess” appears at the top.

25. Note that “WDL” will now post to the “Nursing” flowsheet. This allows other disciplines to determine which parameters have been assessed related to “Defined Normal” definitions.

26. Documenting a “Selected Assessment” • “Selected Assessment” occurs when only one or some of the “Defined Normal” parameters have been assessed. • “Selected Assessment” may occur as part of the plan of care or per a physician order, such as a frequent assessment of “LOC” on the Neurological Form.

27. To document a “Selected Assessment,” click on the eraser icon. (Click eraser now to continue.)

28. Note that clicking on the eraser icon will remove the “WDL” defaults. It also removes information from the “Genview” at the top of the form. (When the form is opened for future documentation, the “WDL” and “Genview” will be present). Prior to clicking on the eraser icon, review the “Genview” information as needed. Under “LOC” select “WDL Except” to continue.

29. If “LOC” was previously charted, when “WDL Except” is selected; last charted value (LCV) pulls forward. Verify that the LCV information is correct, change the LCV information, or chart new information. Then, sign the form to save the information.

30. Note on the “Nursing” flowsheet that when a “Selected Assessment” is documented, only the parameter(s) assessed and documented will post.

31. Form Change: Edema Grid • The edema documentation grid has been changed; multiple rows have been added to eliminate the need to add new rows. • Review the reference text for appropriate definitions of edema, generalized edema and limited use of the term “anasarca” for end-stage system failure.

32. Under “Edema,” select “WDL Except” to continue.

33. “Edema” EBP reference text is available by right clicking the mouse in any of the column headers, or in the “Generalized Edema”, “Anasarca” field. Note that the drop down window will appear, select “Reference Text”. Click on “Reference Text” now to continue.

34. “Edema” and “Anasarca” reference text. Click “OK” to close reference text and continue.

35. Note that the box for bilateral ankle edema is a single select “Alpha” field. Next to “Ankle” click on the box under “Bilateral” to continue.

36. The “Result Details” window for “Bilateral” will open. Note the selection options. Click on “OK” to continue.

37. “Girth Measurement has been added to “Edema”. Note that the information is entered in “Inches” and auto-calculates to “cm”.

38. When documentation is complete, click on the back arrow to continue.

39. Note that all of the other “Defined Normal” parameters are defaulted to “WDL.” Signing the form now indicates that all of the parameters were assessed. Click on the “Check Mark” to sign the form and continue.

40. Note the documentation on the “Nursing” flowsheet. “Edema” and “Girth Measurements” are the only defined parameters that were not within the “Defined Normal” parameter. The documentation supports that all parameters were assessed, which is indicated by “WDL”.

41. Skin Assessment Documentation • The skin assessment documentation grid has been changed; multiple rows have been added to eliminate the need to add new rows.

42. Under “Skin Assessment,” click on “WDL Except” to continue.

43. “Skin” assessment reference text is available by right clicking the mouse in any of the column headers, note that the drop down window will appear, select “Reference Text”. Click on “Reference Text” now to continue.

44. “Skin Integrity” reference text. Click “OK” to close reference text and continue

45. Note the row and column headings. Each box allows for multiple selections. Select the box next to “Skin Abnormality 1”; under “Body Part” to continue.

46. Note that the “Result Details” window for “Body Part” will open, allowing for multiple select documentation. Click “OK” to continue

47. Click on the box under “Spatial Location” to continue.

48. Note the multiple selections available for “Spatial Location”. Click on “OK” to continue.

49. Clicking on the box under “Abnormal Skin Color” will open this charting window. Note the available selections. Click “OK” to continue

50. Clicking on the box under “Skin Conditions” will open this charting window. Note the available selections. Click “OK” to continue