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VCH HED Documentation Changes: Education Tab Safety/Fall Risk

VCH HED Documentation Changes: Education Tab Safety/Fall Risk. Start With the Education Record Tab First. Upon admission, identify the appropriate Care Contacts for your patient. This information needs only to be entered once during the admission (unless there is a change).

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VCH HED Documentation Changes: Education Tab Safety/Fall Risk

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  1. VCH HED Documentation Changes:Education TabSafety/Fall Risk

  2. Start With the Education Record Tab First Upon admission, identify the appropriate Care Contacts for your patient. This information needs only to be entered once during the admission (unless there is a change). The hover-over feature gives a precise description of the expected documentation to that area.

  3. The Education Record Tab now follows the Priority Problems format. Identify who received your teaching as well as other pertinent information. If necessary, use the post-it note to annotate additional comments as usual.

  4. Peds Falls Assessment Score Auto-Calculates • PedsFalls assessment score will be auto calculated • Continue to chart Falls Risk Assessment Interventions for Standard or High Risk

  5. NEW Safety/Fall Risk Documentation • Below PedsFalls Assessment, the new Safety Risk Assessment will display to incorporate everything related to Safety: • Peds Falls assessment will be auto calculated • Falls Risk Assessment included • NEW Safety Assessment to be completed qshift • Safety Monitoring • Safety Care Implemented • Safety Education/Engagement • Safety Notification/Care Coordination

  6. The Safety Risk Assessment and appropriate documentation need to be done every shift and PRN. • Only need to document against applicable fields • You can start a Priority Problem from here, if applicable. Now only need a Priority Problem if the safety issue is driving care or restraints in use • Document Response to Safety Interventions in Nursing Summary and Plan Priorities at end of shift

  7. Restraint documentation, located within Section 2 is streamlined: • Document the “Restraint Status” • Checking “done” to “Restraint Safety and Comfort Care” reflects that you have done all the descriptors seen when using the hovering feature • Document against both of these fields Q2H

  8. Continuing down to Section 4…. • If applicable, document who you notified regarding safety concern and what the plan is • A new fall event is documented from here Please call the HelpDesk if there are questions or issues

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