Legacy Health System School of Nursing E-Chart Orientation Welcome To Legacy ! Welcome to the Legacy Health System. We hope that you enjoy your clinical practice experience on one of our many dynamic nursing units. The purpose of this presentation is two-fold: 1. To describe Legacy’s general principles for documentation of individualized, goal-directed care provided by the interdisciplinary healthcare team using a variance-based model. 2. To describe the core documentation components of Legacy’s electronic medical record- E-Chart. Legacy’s Documentation System Legacy’s documentation system is approximately 70% computer and 30% paper. • Each unit’s nursing station has several stationary computers and several mobile computer units for charting. • There is a forms drawer in the nursing station that contains most of the paper forms used for documentation (i.e. Doctor’s order sheet, preprinted forms/orders, multidisciplinary notes, and MAR). Where are charts found? • The hard copy of the patient’s medical record is found at the charting area outside the patient’s room. #This contains physician orders, progress notes, forms not on E-Chart & face sheet. • The daily chart or clip board is found at the charting area outside the patient’s room. #This contains flow sheets not on E-Chart and the ‘MAR’. Standard of Care (SOC) Notebook • The Standards of Care notebook is found at the charting area outside the patient’s room. #This contains the LHS fundamental patient care directives policies (SOC), complex identifiers, isolation signs, latex sensitivity sign, and other unit specific information sheets. Progress Notes • Utilize the Multidisciplinary Progress Notes to document additional important information relating to the patient’s care and history: >>Document patient activity to and from the unit: Include time/date/mode of transport/initials. >>Document all calls made to MDs: Include summary of conversation, even if orders were not received. >>Document Code/Emergency situations or expanded narratives. LHS Documentation Rules • ERRORS are corrected by person who made the mistake: Draw one line through it, write “error” and initial. • To document LATE ENTRIES, chart current date, time and write the words “late entry” or “addendum”. • With DAMAGED documents, originals will be maintained in the chart followed by a recopied document with note “Recopied on (date) by (name) due to (reason)”. LHS Documentation Philosophy • LHS has a policy that defines variance- based charting and outlines documentation responsibilities (LHS.900.2114) • It is critical as caregiver that you follow the LHS policies • You put yourself at risk professionally when you do not follow the policies Variance Based Charting 1. A variance is a deviation from the expected outcome during the patient’s course of care. 2. A variance is also a deviation from the expected or standard interventions and those interventions that the patient actually received as listed in -Standards of Care (SOC) -Physician’s orders -Interdisciplinary orders -Clinical path/plan of care Examples of Variance-based Charting 1. You do not take your patient’s vital signs at 0400 (which were ordered) as you judged that they were not needed. You must document this as it is a variance to the planned interventions in the Standard of Care (SOC). 2. Your patient C/O severe lower abdominal pain post urinary catheter removal. You must document this as it is not an expected outcome of urinary catheter removal. LHS Standards of Care Standards of Care Question: What are the LHS Standards of Care (SOC)? Answer: The SOCs are a pre-printed “script” that describes expected, routine or basic care that the Interdisciplinary team provides for the patient. Each SOC is a POLICY, so as a caregiver, you are accountable to provide the defined care to the patient. The SOCs are written to be population specific (e.g. critical care, pediatrics, NICU, psych) and condition specific (e.g. pulmonary, surgical, orthopedic). Three sections of the SOC There are 3 sections to each SOC 1. PATIENT EXPECTATIONS: Care provided will assist the patient/family/guardian in meeting the following expectations. 2. INTERVENTIONS: The RN coordinates the interdisciplinary plan of care and applies the nursing process. 3. INTERDISCIPLINARY PLAN OF CARE: Within each discipline’s scope of practice, the interdisciplinary team collaborates in providing the following care as warranted by patient condition and caregiver judgment. ***Signing the SOC/Ordered Interventions is the only way care providers at LHS can permanently record that they provided care according to the patient’s plan of care and the timeframe that they cared for the patient. SOC notebooks are located outside every patient room. Definition of words in the SOC Question: What does assess and reassess mean in a SOC? Answer: DO IT (the ordered intervention) and DOCUMENT your findings @ the stated time frequencies. Question: What does monitor, initiate & provide mean in a SOC? Answer: DO IT at the stated time frequencies, but, you don’t necessarily need to document the intervention unless there is a change from your baseline or significant additional information. ***At the end of your shift you document to your SOCs. If everything was completed, you document SOC “met”. If you can’t get something done at the time frequency stated in the SOC INTERVENTION section, this is a VARIANCE to the expected course of care, and the RN/LPN/Interdisciplinary staff member MUST chart that the SOC was “unmet” and chart what intervention was not completed. Who initiates the SOC? Question: How do the Standards Of Care work? Answer: An RN must initiate the appropriate SOC (s) when a patient is admitted and keep them current throughout the hospitalization. SOCs may be superceded by physician/LIP orders (e.g. the SOC may require that VS be taken at 2400, but the physician writes an order not to awaken the patient at night for VS). SOCs may be superceded by nursing judgment (e.g. you decide not to awaken a patient at 0400 as directed by the SOC. *In this situation, you would document that you did not meet the SOC and the reason(s) why. Patient Goals Patient Goals Question: What are patient goals? Answer: Evaluation statements of how the patient is expected to progress (e.g. Tolerates diet, no lab values in critical range, hemodynamically stable). Question: Why have patient goals? Answer: The State Board of Nursing dictates that we have a method of evaluating the patient progress against the Plan of Care and adjust that plan accordingly. Question: How often do patient goals need to be addressed? Answer: At least ONCE each 24 hours Question: Who can address patient goals? Answer: An RN (not an LPN) or other licensed healthcare team member (e.g. RT, PT, OT). Complex Identifiers (Referrals) Complex Identifiers • Provides a method for interdisciplinary referrals (Process to refer patient to RT, PT, wound nurse, IV resource nurse, nutritionist, etc.) • Provides guidelines for referrals • The only complex identifiers that require a physician order are for PT, OT, or Speech. • Example If the patient’s Braden Score indicates that a referral for wound care is needed, the Complex Identifier for wound care needs to be ordered. Electronic Medical Record E-Chart Sign-in Screen Signing in to E-Chart • Your instructor will give you a user name. Your first password will be ‘begin’. The computer will prompt you to change your password every 3 months. • Help desk – 55888 • Security/confidentiality. No employee/student has the right to access or disclose patient information except as necessary to fulfill his or her job responsibility. • Breaches of confidentiality might include: reviewing data of family, neighbors, co-workers, local celebrity, patients transferred out of your unit and looking up information about yourself. Base Screen 3 2 1 This button takes you Back to the base screen 1. Nursing Base Screen: A list of all patients on your unit, or on your hotlist. 2. Patient List Directory: Patient lists. (Hotlist is a list that you create which contains your patient assignment.) 3. Action Buttons: Short cuts to information and documentation areas. Tool Bar Icons 1 2 3 5 6 4 1. Back one screen 4. Delete patients from your hotlist 2. Next patient, or previous patient 5. OK = enter, send, save 3. Back to base screen 6. Stop sign = sign off Click on LocCen to pull up the census for your unit To create your Hotlist A Hotlist is a list of your assigned patients. To make a Hotlist, double click on each of your patients. After choosing all of your patients, double click on Hotlist. Title Bar When a patient’s name appears in the title bar, their chart is open. ROI (Release of Information Status) If a family member calls or comes to your unit, you may give out the following information depending on the patient’s ROI status. • Full release– name and room number • Partial release– name only • No release – no name or room number (all ‘patient holds’ and psych patients are no release) Chart Tabs At a Glance chart tab - To find an inpatient, go to At a Glance chart tab. At a Glance Chart Tab Type in patient's name, click on activate patient or enter on the keyboard. (**Note Release of Information Status). At a Glance Chart Tab to find Allergies and Weight Add or delete allergies here, then click on Next Page/Intolerances Add or delete allergies here, but do not add height or weight. Food Allergies & Non-Med Allergies (2nd page) Add food allergies and non-med intolerances here. Transcripts Chart Tab Transcripts Chart Tab The symbol “>“ identifies the report you are viewing. To view other reports, double click on the specific report. This will bring up the report to the right of the screen. Diagnostic Reports View diagnostic reports under the Transcripts chart tab. Lab Chart Tab To find lab results, go to the Lab chart tab. Views Chart Tab Choose the view you want and double click. Worklist Chart Tab Plan of Care found here! Plan of Care Includes: 1) Clinical path, 2) SOCs in effect for your patient, 3) Goals, 4) all orders, 5) location to sign to the SOC. Plan of Care There may be more than one page to the Plan of Care (use the down arrow on the right to get to the second page). Flowsheets Chart Tab Includes: VS, Patient Teaching and I & O VS Flowsheet Use the control key to highlight what you want to chart to and then choose Enter Data. VS Flowsheet Add result here (change time if needed). VS Flowsheet To delete or change a result, highlight the row, click on the Detail/Chg Data button. VS Flowsheet Highlight result, then choose the Change Data or Delete Data button. Delete screen Click on Delete Data. Change screen Change result, then Enter. I & O screen (found under Flowsheet Chart Tab) I&O Screen • For each entry, you will fill in the result field and have the option of entering a modifier. • Try to limit the number of modifiers you use. Otherwise, your patient’s I&O flowsheet will become really long and confusing. • For example, you may make a modifier for JP#1 under drains I & O Flowsheet Click on the items you want to chart to. I & O Flowsheet The totals are listed at the bottom in blue. IV Fluids Click on IV Fluids to document IV fluids. IV Fluids Add results, choose a modifier from the dropdown box, then write LTC under comment (LTC: left to count). IV Fluids To add additional IV fluids: Click on IV Fluid and enter data. IV Fluids Add amount to the result and LTC to the comment line. IV Fluids Wasting IV fluids Make a modifier Make a modifier. You may use the drop down box or type in a modifier (JP#1) Patient and Family Education • Documentation of patient and/or family education should occur AT LEAST every 24 hours. Ideally, this documentation takes place each shift. • For example, if you have a patient that you are educating about multiple discharge medications, simply have one modifier labeled ‘medications’ where you track all of this data. You can type in the individual medication that you were teaching in the comments section of that entry. Always try to be very specific in your comments section. If your modifier is a general entry such as “Plan of Care,” make sure that you delineate what you specifically taught in the comment’s field! Patient Education (Flowsheets Chart Tab) Always document to: 1. Content/Eval, 2. Learner, 3. Assess readiness, 4. Teaching method Assessment Documentation • Every nurse should be using the same criteria to guide the type of data they collect for their patient assessments. Literature finds that this does not occur without guidelines. • Therefore, Legacy has created system- wide assessment statements that act as guidelines to ensure that the patient data collected during a shift assessment is consistent and covers the parameters of a minimum assessment. These are called Norm Statements. Norm Statements The nurse assesses all the components of the Norm Statement as a minimum assessment. The nurse will always assess/observe MORE than what is covered in the Norm Statement. Example of an Adult MedSurg Cardiovascular Norm Statement: “AP regular, skin warm and dry, mucous membranes pink and moist. Extremities warm. Cap refill </= 3 seconds. No edema.” This means that the nurse assesses/observes the apical heart rate, skin, mucous membranes, warmth of extremities, capillary refill, and presence of edema. (The nurse may also want to assess pedal pulses, calf tenderness, heart sounds and pacer wires.) Norm Statements • If a patient’s assessment MEETS the Norm Statement exactly for that category, the nurse indicates time and initials in the space preceding “meets norm statement.” • The nurse may add more information to EXPAND on this assessment in the “note” space. E.g., if the nurse checks pedal pulses (not part of the med/surg minimal assessment), the nurse may add information about this such as “pedal pulses faint but palpable.” Add only assessment information not already covered in the norm statement. • A patient CAN meet the norm statement PLUS have additional findings in the Note space. Norm Statements • If the patient Does Not Meet the norm statement, the nurse puts the time and initials in the space preceding “does not meet norm statement” and types in the specifics of what is NOT met, e.g., Skin moist with dependent edema in feet.” The nurse does NOT comment on what was normal such as the apical heart rate, skin, mucous membranes, warmth of extremities, and capillary refill. • If the patient’s assessment is the same as the previous assessment, then it is acceptable to make a note that says “same as 0800” (always indicate a time). Shift Assessment To document the Shift Assessment, click on the Assessments button. Shift Assessment Existing assessments are listed on the left and NEW assessment forms are listed on the right. Shift Assessment Choose your specific area Shift Assessment Choose the specific form you need and double click. Choose All Categories Shift Assessment Click on Exit when finished with the VS screen Put an “x” in each box in both columns by clicking in each box. When done, click on Save and Next Shift Assessment Type time and your initials on the line in front of Meets or Does not Meet Norm. Make a note as warranted. Shift Assessment Remember to always make a note when choosing Does Not Meet. Shift Assessment When documenting a follow-up assessment, pick from the Existing Assessment section. Shift Assessment Choose adult shift assessment, then Save and Next. Shift Assessment To return to assessment field you must update the text window by using the drop down box to the left of the Note column. Never take an “x” out once it has been placed in the column. Shift Assessment To document an error, type in Error with your initials in front of your note, then document the correct findings below. Shift Assessment If you delete information in the shift assessment by mistake, go to Edit, and Undo. Sign to the SOCs Go to Plan of Care, click in the result column next to **SOC;SOC/ORDERED INTERVENTIONS, then right click. Choose SOC Met Double-click on SOC Met Signing to the SOCs Click on SAVE Signing to the SOCs Type in the time you took care of your patient and click “OK” Then click on Exit To Document SOC Unmet Follow the same process, choose *SOC Unmet, then SAVE SOC Unmet Document the time you took care of your patient and document what in the SOC was not completed Patient Goals To sign the Goals, click into result field and right click Choose Goal Met or Unmet Goal Met or Unmet Once you choose Goal Met or Unmet, click on SAVE. Complete one screen at a time. Clinical Knowledge Base Care Notes (patient teaching sheets) Choice of teaching sheets in English and Spanish Example of a Carenote LHS 100-800 Policies Double click on the link to the right to view or print LHS Patient Care Policies Patient Care Policies Use text book “Nursing Procedures” (4th edition), if no LHS policy listed. (See page number.) Blood and Blood Products Policy You are done!! You are now prepared to document your patient care in Legacy’s Electronic Medical Record- E-Chart!!