Charting a New Course for Patient Documentation

Super User Training

Manual

Set Up

  1. Pull up the Nursing Documentation Super User Power Point
  2. Distribute to each terminal: Pt Name Card
  3. Flip chart or use Board- write trainer’s names – have markers to record responses
  4. Sign In Roster
  5. PPT: super user class nursing doc
  6. Handout to take back up
  • Copies of Culture change presentation to staff ( for reference – don’t need copy for every)
  • Super User Support Guidelines
  1. VIDEO CLIPs ( Not ready 7/18 )
  2. what would you do with 20 minutes
  3. RISK MANAGEMENT
  4. Role Play exercises 1-5
  5. Handouts:
  6. Job Aide
  7. Nursing Documentation Guidelines Policy
  8. Unit Practice

Welcome/Intro/ Vision : (10 minutes)

Show slide #1

  • Introductions
  • Restrooms
  • Length of class is 2 hours

What you will learn today

TrainerShow slide #2

Thank You

Trainer: Show slide #3

The Super User role is vital to implementation of this change. We want to thank you for agreeing to be a super user.

Why Chart a New Course

Trainer: Show slide #4

This pie chart is the amount of time nurses spend doing various activities from time studies that were conducted.

  • What are we doing the most? Documentation a whopping 35%!
  • Clearly- nurses need more time with their patients less time writing about what they are doing with their patients
  • These documentation revisions are to re-distribute the pieces of pie
  • Nursing documentation is very important to patient care. Nurses are really telling the story of the patient. So we wanted to be sure we told this story well. Just cutting out fields in HED doesn’t help tell the story better. Documentation is also there to help support other disciplines – providers, RT, PT, Dieticians, SW, etc….
  • Shifting our thought to value – how we make sure everything that the nurse is documenting is valuable and contributes to that story and informs the care you and others give.
  • Just cutting out time isn't the entire goal – we are putting value back into what nurses document!

Every minute is important. Every field should be important!

FOCUS

Trainer: Show slide #5

The new documentation is being designed for use by proficient, ethical nurses

  • will be challenging old thinking that often resulted in added documentation to address performance issues of very small numbers of low performers.
  • additional documentation burden penalized all nurses
  • often did not achieve the desired outcomes of bringing deficient practice up to standard.
  • old ways of thinking are very ingrained so during this initial communication period, one of our biggest opportunities is “myth busting”.

STOP

Trainer: Show slide #6

Myth Buster Section (3 minutes)

What would you do?

Trainer: Show slide #7

ASK …What would you do…..With 10-20 minutes more in your shift?

Hopefully you have already discussed this in a staff meeting, (if not your manager will be covering this )

If you had 10-20 minutes time back per shift due to less time spent on documentation, what would you be able to do with your patients and families during that time that you cannot do now?

Allow time for response: Users to call out…

Impt that they be able to verbalize this to others as they are role modeling this as a super user.

WHEN READY….VIDEO CLIP – what would you do with 20 minutes

Myth Busters

Trainer: Show slide #8

So if we all agree that we want to put value back in our documentation and spend more time with the patient vs writing what hold us back…. Why is it so hard to change.

  • There are some beliefsthat are just not correct
  • If it’s not charted it’s not done
  • Misconceptions about regulatory requirements
  • Quality of documentations = quality of my care
  • Transition to this new process will involve changing the culture and some deeply held beliefs and challenging misconceptions.

We need you to be the myth busters….

MYTH 1:

If it’s not Charted, its not done

Trainer: Show slide #9

  • Fundamental beliefs from nursing school or orientation to our first jobs.
  • Reinforced for so long by so many people and situations that you would have no reason to consider thinking or feeling a different way.
  • We are asking you to be open to new ways of thinking based on evidence and facts and hope you will be willing to think in new ways that will allow you to alter your documentation practices.
  • Risk Management tells us this is just not true!

VIDEO CLIP – RISK MGT- NOT READY YET

Myth 2:

“I have to chart this because it’s required by … “ [Joint Commission, Hospital Policy, Risk Management, etc.]

  • Joint Commission standards require certain outcomes – for example, screening for nutritional risk factors that would warrant a consult to a Dietician
  • BUT they do not mandate what that screening process looks like or specify what must be documented
  • The same is true of many regulatory requirements
  • Generally want us to follow our own policies
  • Our documentation policies are about to change drastically and one big outcome from that will be a reduction in quantity of documentation required

HANDOUT OUT DRAFT POLICY: Nursing Guidlines– we’ll reviewmore closely later

MYTH 3:

  • “Quantity of documentation = quality of care I provide”
  • If I don’t document a lot it looks like I haven’t worked hard
  • This is not nursing school where you get a better grade the longer your care plan is
  • Changing long-standing, deeply held beliefs is not just about facts.
  • We also have to understand the emotions and values associated with those beliefs

IMPORTANT- We need staff to BELIEVE that changing their documentation is NOT going to negatively impact the quality of care their patients receive.

ASK: What other documentation myths should we add to this list?

Allow time for responses- - NOTE on FLIP CHART

Will result in staffing changes

Trainer: Show slide #10

We are reducing documentation in order to increase nurse to patient ratios or make other staffing changes

NOT TRUE!

No further changes are planned to the staffing models. Documentation reductions are needed to make the model work better.

No staff nurse involvement

Trainer: Show slide #11

Those making all these changes are out of touch with what really happens at the bedside- these changes will never work.

NOT TRUE! Many were involved in developing the revisions!

“Real Nurses” were involved

Trainer: Show slide #12

Here is a list of the various committee members that have worked on these changes… these are real nurses giving input and making decisions about revisions

ASK Are any of you that worked on the revisions here in class today? Allow users to respond.

What is NOT changing:

Trainer: Show slide #13

  • Care Organizer & Admin-Rx
  • General format of HED screens and how to select items from drop down menus or typing annotations
  • Nursing Admission History will continue to be documented in StarPanel
  • Clinical Care Classification (CCC) (SABA model) standardized terminology for documentation of problems
  • Required documentation denoted by ALL CAPS
  • Concept of Priority Problems/goals- (but HOW these are documented is being simplified)

Patient Scenario

Trainer: Show slide #14

The Nit and the Grit of the changes

Trainer: Show slide #15 (sign on with own ID, choose HED train, use pt on handout)

HANDS-ON (1hr 5 min)

Trainer/Learner: Sign on to CWS and Click HED train icon. (minimize the ppt)

From Care Organizer, Click HED button

Select the patient on your card

In the training region you will see both the current tabs as well as the new tabs.

The new tabs are in ALL CAPS.

Locate these tabs

  • Plan
  • Vitals/I&O
  • Assessment
  • Interventions
  • Devices
  • Education
  • Protocols

Old VS New Tab- How to tabs on Nonimplemented units

  • Show slide #17

There will be fewer tabs and they will be re-ordered.

The PLAN tab will be the first tab displayed followed by the Vitals I&O tab when we go live… right now in train you still see the Vitals and I&O first.

Instead of having various assessment and intervention tabs for different ptcare areas, all assessment documentation regardless of pt location will be in the assessment tab.

Interventions tabs now separate to make it quicker to go directly to documenting care rendered.

New-Devices tab to document information re: devices – ICP, LVAD etc..

Education tab consolidates all education related documentation – including discharge readiness.

Are you the type of person that wants to see everything in one place, and doesn’t mind scrolling? Use the new ALL DOC tab where most data from the other tabs are displayed.

There will not be tabs specific to clinical areas (AKA med/surg, ICU, Peds).

ASSESSMENT TAB

Trainer/LearnerClick on the Assessment Tab(Show All if collapsed)

You may notice:

•Decreased Care Categories (menus on left side of HED)

•There will be fewer items in the list

•Some things have been consolidated- for instance all the IV associated items will be listed under the new “lines” category

•Every care category should be addressed upon admission

NOTE EXCEPTIONS:

•Reproduction assessed on OB, GYN & GU only

• Lines only if pt has an IV

•CAPS designate required documentation for every shift and change in level of care (not changed).

•Data required for approved population based decisions support (Braden PU scale, Glascow coma scale) or to meet current regulatory requirement will be addressed every shift

Reviewof Care Categories

Let’s practice documenting for a patient we have just rec’d from the ED as a way of getting familiar with the care categories.

Pain

Note: Pt was given pain med in Admin-Rx so we are not double documenting that in the assessment or intervention section but will document the pt’s pain score 30-60 minutes following med administration or interventions for pain.

We will come back to Reassessment.

Neuro

Trainer/LearnerClick Neurological in the care category list (Show All if collapsed)

Trainer/LearnerClick NEURO ASSESSMENT

Trainer/LearnerHover over Neuro ASSESSMENT to display the normals

This neuro assessment will be the place to document the status and if there is a problem. Note the drop down boxes.

Note the various categories…

You are familiar with WNL and the SABA problems (notice you do not have to click a link to start a priority problem, you start it from this drop down).

ASK What do WEL & OEL mean? Look at your Job Aide

HANDOUT -Job Aide

PROBLEMS

Abnormal finding rise to the level of being actual problems if:

it is a problem for the patient/family

the problem is one of the primary reasons the patient is hospitalized and will be a primary focus for care provided

the patient is at high risk to develop a serious complication

NEURO

Trainer/LearnerClick WNL because pt is alert and oriented X3 w/o neuro issues.

ASK Notice NEURO ASSESSMENT is in all caps. What does that mean?

(Response – must be documented on every shift)

Cardiac

Trainer/LearnerClick CARDIAC ASSESSMENT

Trainer/Learner Hover over CARDIAC ASSESSMENT to display the normals.

The “hover over” information has been greatly enhanced with the documentation revisions.

Instead of documenting standards or “normals” reference the hover overs for that information.

In this example when hovering over cardiac assessment, you can see what WNL means and thus eliminate the need to document all the normal values if the pt has no problems.

You note the pt is in afib w/o symptoms. The pt reports that they stay in a fib and this is considered their norm. What would you document?

Trainer/LearnerClick WEL since this is the pt’s norm.

Trainer/Learnerannotate”A fib X5 years w/o symptoms per pt”Since this the first time assessing this.

If pt were on telemetry or a monitor, we would also document under EKG rhythm- A Fib.

Vascular/ perfusions

Trainer/LearnerClick Vascular / perfusion assessment and denote it as WNL.

ASK“This care category is not in all caps. What does that mean?”

(Response- must be documented upon admission and if abnormal must be charted every shift or as condition changes – but if WNL/WEL doesn’t need to be charted every shift.

RESP

Trainer/LearnerClick RESP ASSESSMENT

Trainer/LearnerClick Gas exchange alteration

Document

  • Wheezes present in BLL
  • cough w productive secretions- thick yellow sputum

ASK: what do you chart in R & L Upper Lobes?

Nothing, they are normal.

GI

Trainer/Learner:Click GI ASSESSMENT

Trainer /learner document: Pt has hypoactive Bowel Sounds but otherwise no GI issues.

ASK“What would you select?”

Response: OEL(outside expected limits)– why- because that isn’t normal but it hasn’t risen to status of being a problem but will need to be reassessed to assure it doesn’t develop into a problem.

Trainer/LearnerClick OEL, then under bowel sounds field, select “hypoactive”

SKIN

Let’s skip down to skin. In a real admission you will document in each care category.

Trainer/learner documentpt has stage 1 PU on L buttock, select in the skin assessment category, Choose Pressure Ulcer

Trainer/Learner document Start a wound for the PU (there is no change in this process)

Braden hasn’t changed, it must be documented on each shift. If the pt is at risk, it will automatically display in red.

FALLS RISK/SAFEY

  • This is required every shift for VCH.
  • VUH : Fall/Safety Assessment & fall risk status every shift. Morse scale on admission, transfer, or after fall event.

LINES

Trainer/Learner:Open lines, Note that all lines are listed here. Starting a line hasn’t changed otherwise.

We won’t take time to document the IV here.

In real life you would document on each care category upon admission.

SAVE

Trainer/Learner Click Save (BUT DON’T CONFIRM YET)

From the Save and Confirm screen, reviewthe list of problems that were identifiedduring the assessment.

Trainer/Learner Identify the top 2-3 priority problems by clicking on the !!. This will denote these problems in RED text on all screens.

Remember that there are shades of gray to selecting problems and their priorities. Intent is to tell the pt story.

Trainer/Learner Identify Save and confirm

REASSESSMENT

Trainer/Learner: Click on Reassessment (look at handout)

After the initial assessment, reassessments are continually done by the nurse. The practice of re-assessing your patient is NOT changing but when that re-assessment must be documented is changing.

Re-assessments are documented as warranted based on orders and or patient condition and per unit standards

Timeframes:

•ICU – at least two more times during the shift

•Acute Care – Document re-assessment if patient condition changes. Documenting Response to care at the end of your shift will summarize any changes in your patient otherwise.

Reviewthe care categories thar are prority problems, problems and OEL to see if there are changes.

If the patient is stable in some or all categories only document “unchanged”. If there are changes document “unchanged except”and then denote only the changes. Remember we want the differences to stand out so don’t document those items that have not changed.

Pain must be documented with each re-assessment only if the patient was experiencing pain > than pain goal they had set. Remember to document pain score after administering pain med.

Trainer/LearnerDocument Unchanged except and denote that pt now has nausea- mild.

ASK?

“What do you have to document on Admission?”

  • All care categories-
  • EXCEPTIONS: document reproductive on ob/gyn/gu pts only and lines only if pt has iv lines.

“What do you document on every shift?“

  • Care categories in ALL CAP
  • Braden, Rass etc.
  • Other categories if there are problems or OEL

When do you document the reassessment section?

•ICU – at least two more times during the shift following the initial shift assessment

•Acute Care – Document re-assessment if patient condition changes. Documenting Response to care at the end of your shift will summarize any changes in your patient otherwise.

Trainer/LearnerClick Save & confirm

Add a problem later in the shift:

During reassessment, you now determine an area to be a problem you can click on the reassessed value to modify it by click on the exclamation point.

It will now show up in the Plan section. You can click on either, the category OEL or the finding and modify it by clicking on the exclamantion point.

Education

You have collected the patient’s care contact information as well as oriented the pt and their family to the VUMC and unit. Document this information in the Education tab.

Trainer/Learner clickEDUCATION tab. (Show All if needed)

Trainer/LearnerEnter Care contact information – be creative and make up some data

Trainer/Learner Click theEducation section.

Scroll to notice discharge at the top, then generic educational info – then disease specific (corresponds to KRAMES categories)

Click Pulmonary and select Conditions. Annotate Pneumonia

Click on Links and open Krames (under misc), type pneumonia to locate education. In real life we would print this document to give to the pt.

ASKWhere would you document this handout? Handout(annonate) –the handout name

Trainer/Learner In Handouts type: What is Pneumonia (name of handout)

About the Education Tab

  • Patient & Family education is an ongoing process and part of our care standards. Documentation is focused on the outcomes of education, rather than the individual components of a teaching session. So be sure to document patient/ care contact response to educational sessions.
  • Per input from nurses, instead of documenting learner, challenges and engagement for each topic, now documented once for each educational session
  • Educational categories and dropdowns, mirror Krames. Denote in Handouts names of documents or educational “bundles” or Krames #
  • Free text field - If other material is used or to denote additional information there is

Trainer/Learner :save and confim