Routine Job System in Chart Type

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					     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-
     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
• 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
#This contains flow sheets not on E-Chart
  and the ‘MAR’.
   Standard of Care (SOC)
• 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
  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
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

  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
Electronic Medical Record
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
• 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



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


    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
  (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

• 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
             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
• Try to limit the number of modifiers you
  use. Otherwise, your patient’s I&O
  flowsheet will become really long and
• 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
          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
         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
         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
Blood and Blood Products Policy
      You are done!!

You are now prepared to document
   your patient care in Legacy’s
    Electronic Medical Record-

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