If documentation is a reflection of our care, does it show that nurses make a difference ?

1. If documentation is a reflection of our care, does it show that nurses make a difference?

2. Falls/Safety Documentation Changes – Why change? • Changing focus from repetitive screening for Falls Risk to a model that supports Falls Prevention • Historically for each new issue addressed, we’ve added a new section or Tab to HED – not sustainable and adds complexity to documentation • As we work toward a Culture of Safety, we need a framework that allows us to identify and address all safety risks efficiently and document all education in a compliant, simpler fashion

3. OBJECTIVES…. • Verbalize understanding of the changes in documentation and workflow associated with new Falls/Safety HED build • For your area, identify common Falls/Safety scenarios and how to address them Use a practice scenario to document Safety Assessment and Plan including: • Determine the Morse Falls Risk Score • Identify safety risk factors and safety problems; Start Safety Priority Problem, if warranted • Document Care Interventions, Patient/Family Teaching, and any Notifications & Care Coordination actions • Document response to safety interventions & shift goals/outcomes for Safety Priority Problems (if there is a Safety Priority Problem)

4. Vision Statement Safety Documentation, including assessment, interventions, teaching, and notification, will result in a safer environment for our patients and will prevent or minimize injury. This will improve patient care and clearly define nursing’s contributions to patient care and the team.

5. Safety/Falls Section: What’s Changing? • Safety assessment on every patient, every shift. Also: • Adults: Morse Falls screen • Peds: Humpty Dumpty Falls • on admission & with change in status/condition (e.g. Transfer to different level of care, change in mental status, etc.) . No longer required every shift. • Streamlined documentation of Restraint Safety Care • Safety Problems(Injury Risk, Violence Risk, Substance Abuse, and others) will be identified. • If a safety problem will be a key driver of nursing care for that patient, also initiate as a Priority Problem • CIWA documentation will be available in HED for units that implement CIWA protocol • Safety Interventions will be documented – things you: • Assess/Monitor/Evaluate/Observe • Care/Perform/Provide/Assist • Teach/Educate/Instruct/Supervise • Manage/Refer/Contact/Notify

6. Education Tab: What’s Changing? • Caregivers’ contact information (“Care Contacts”) – will be documented in new Role/Communication section • Patient/Family Education & Engagement will be documented in a way that captures required elements more efficiently

7. What’s Not Changing • Plan of Care documentation • Priority Problems – continue to create and evaluate goals • Pathway, Nursing Summary, and Plan Priorities documentation in HED • Continue to assign e-docs pathway • Admission History • Continue to complete all sections (Contact Information will likely be removed in future)

8. What to Do & When • Admission • Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems & Plan Interventions; Start Priority Problem if warranted • Beginning of Shift • Safety assessment; Identify problems & Plan Interventions • Document expected Short Term Goals for Safety Priority Problems • Start/End Safety Priority Problems if warranted • Document Short Term Goal Status or outcome for Priority Problems • Document Response to all Safety Interventions in Nursing Summary and Plan Priorities • End of Shift • Falls Risk screen • Repeat Safety Assessment & Revise Planned Interventions as appropriate • Condition/ Status Change

9. PRACTICE SCENARIO – Admission • John Doe is an 85 year old male admitted for planned TURP for BPH. • Medical Conditions: COPD, Heart Disease, Hypertension, and migraine headaches. • Past Surgical Procedures: CABG (1987) Bilateral Knee Replacements (1997) shoulder surgeries (2002 & 2005). He has a history of falls with injury (2 within the last 3 months), resulting in rotator cuff tears and multiple rib fractures. • Medication History: 15 medications, some are anticonvulsants, Lortab for poorly controlled headaches, 2 antihypertensive, and Lasix. • Family/Support: His wife, the primary caregiver, shares that a lot of medications make him “dizzy” or “crazy”. She reports that he has stopped taking many medications because the side effects contributed to falls. • On admission: Mr. Doe has no IV, is alert and oriented x3 , and verbalizes awareness that he is very unsteady on his feet. He has Activity orders is to be OOB w/Assist and agrees to use the call light any time he needs to get out of bed. His wife is concerned that he may try to go to the bathroom without assistance because of urinary urgency and frequency associated with his prostate issues. His daughter will be secondary caretaker and will come on the weekends to relieve the wife.

10. Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems & Plan Interventions; Start Priority Problem if warranted Admission • Click on HED Train tab and select the Safety Falls/ Risk tab – this will be inserted in the assessment tab for your unit on GO LIVE date • Locate and complete the Morse Falls Risk Section

11. Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems & Plan Interventions; Start Priority Problem if warranted Admission • Use the hover over box to see more information on: • Ambulation aid • Gait

12. Morse Falls Risk screen • Safety assessment as part of head-to-toe assessment; Identify problems & Plan Interventions; Start Priority Problem if warranted Admission • Document the Safety Assessment on admission. • Consider creating a Safety Priority Problem, only if it is 2-3 of the main problems for patient on current shift. • Restraints should always have an active Priority Problem and goal • Click on the Education tab and document contact information for “care contacts”

13. Safety assessment; Identify problems & Plan Interventions • Document expected Short Term Goals for Safety Priority Problems Complete Safety Assessment qshiftand with condition/status change Complete Morse Falls Risk Screening on admission and condition/status change only (not qshift) Beginning of Shift

14. End of Shift • Start/End Safety Priority Problems if warranted • Document Short Term Goal Status or outcome for Priority Problems • Document Response to all Safety Interventions in Nursing Summary and Plan Priorities • Continue to start and end priority problems • Continue to evaluate goals at end of shift • Identify patient responses to Safety Interventions in Nursing Summary and Plan Priorities NEW

15. Common Questions Answer: No, only on admission & changes in condition/status 2. Yes, but only two fields 3. Sometimes but not all Safety issues rise to that level. Question: 1. Do I document a Falls Screen every shift? 2. Do I still need to do document restraints every 2 hrs. ? 3. Will safety issues still be Priority Problems?

16. GO LIVE DAY Check with CAPS on GO LIVE dates for your area New Safety/Fall Risk section will replace the old Falls Risk section in Assessment/Interventions tab New content will appear in Education tab Restraints tab will be removed Past data will be viewable for the Restraintsand Fall Risksections of Assessments/Intervention Tab but will not contain charting boxes.

17. Training and Implementation Plan • Resources: • Provided by SSS: • All resource materials will be accessible from Systems Support Services Web Site by Sept. 25 • CAPS will partner with Unit-Based Resources to complete education & will provide support • Provided by Unit: • Super-Users/ Educator • Need enough super-users for each shift Go Live week • Implementation Support • Super-user: 9a-5p and 9pm to 5am • SSS: 9a-5pm and 9pm to 5am (Night Shift will support multiple units concurrently; rounding schedule to be posted)

18. Unit Leader TO DO LIST • Meet with CAPS person to formulate specific plan for our unit • Review the documents provided (posted on SSS website) • Complete Unit-Specific Implementation Plan (including recruiting Super-users) and use that Plan and Implementation Checklist to track progress through implementation process • Identify Super-users and best way to do training for your unit ASK QUESTIONS