FAQ
Question / Answer1. Where do you document emergency equipment at the Bedside? / Having appropriate safety equipment (e.g. Ambu bag w/ appropriate sized mask for all patients; extra Et tube or Trach as appropriate) at bedside is part of the basic standard of care and does not need to be documented. In the Safety/Falls Interventions section, there are safety interventions that include a very small number of items including wire cutters.
2. How do you document numerous chest tubes? / In Respiratory Interventions, there is a place to document up to 5 different chest tubes. (These are not under the Tubes and Drains section but are separate and documentation about Chest Tubes is NOT changing with new build.)
3. What about RASS requirements? / RASS documentation requirements have not changed.
See hover for more details:
4. In most acute care units they are not documenting a re- assessment one other time in their shift – are we going to change this standard and make them document the re-assessment one other time? / Patient Response to Care entry could replace documentation of “Unchanged” on Acute Care Units. (with “Unchanged Except”, you’d need to chart the changes.)
5. Where do you document poor appetite? Where can you document that the patient is not eating much?
6. Where do you document % of meal intake? / If it is a priority problem, Nutrition Goals include options for meal % intake. Annotate if not priority problem.
Nutrition sub score of Braden also includes information on nutritional status.
Meeting planned with Nutrition to discuss potential to provide patient/family with a self-reporting tool to document % of meal intake that would be used by Dietary and Nursing. % of meal intake will no longer be documented in HED.
7. Where do you document poor skin turgor? I.e. decreased elasticity that you would see w dehydration? / “Skin color/condition” – skin category.
8. There are normal listed when documenting IV site appearance- are there supposed to be? / Yes “Normals” (dry/intact) for initial assessment of shift
Please note that “IV site check” box is no longer available. The IV site should continue to be assessed per policy, but the documentation requirements have changed. Document assessment with initial shift assessment. Document if any changes occur.
9. What if an IV infiltrates? / There is now a place to document the last IV site check when you discontinue an infiltrated IV. You should continue assessing & documenting on the “ended” IV line after an infiltration.
10. What is Respiratory Monitoring (Interventions)?
Is that pulse ox? / Monitoring respiration via bedside monitor, Covidien monitoring (SaO2, ETCO2), continuous pulse ox, etc. See hover for more details.
11. Where do I chart HOB elevated? / In Activity/ Musculoskeletal Interventions, under positioning interventions.
12. Are the ECMO, CRRT tabs staying? / Yes. Access from the “Chart” button if the tabs are not showing:
13. Where is Pacemaker documentation?
14. Berlin fields? (artificial heart) / See Device Tab
Berlin fields will only show on 5A devices
15. How do you document Bowel Mgt systems – flushing, Initiation, status / GI interventions – “Bowel Mgt. care” means you provided care as specified in BMS procedure. No need to spell out each element.
16. Why don’t we have the ability to say each goal is either met or not met? / In many cases, the answer is not just “yes”. By using a narrative entry under “Patient Response to Care”, richer detail can be included (e.g. What interventions did/did not contribute to improvement? If goal was not fully met, what would you recommend the oncoming nurse try based on your experience?) This is one of the key ways documentation “tells the patient story.”
17. Where is documentation of: CVP (central venous pressure)
CVP reading in VS
What about Zero transducer?
Waveform? / In ICUs, CVP is generally done from the pressurized invasive monitoring line to that documentation is done under the art line assessment (which includes options about things like dampened wave forms, etc.) Zeroing transducer before documenting a value is standard of practice and does not need to be documented.
When CVPs are monitored outside of ICUs, they are generally done manually with a manometer and there is no waveform or transducer involved.
18. Alarm limits? / There is a place at the bottom of the Device Tab to document Alarm Limits BUT we are not sure this is necessary. This is being looked at by Clinical Practice.
19. ICUs: Do we still have to document q2h? / Assessment does not equal documentation. When unit-specific policies require assessment at specified intervals (q I, 2, or 4 hrs.) the assessments are done at least that frequently. Unless the unit-specific policy requires documentation of that assessment at a specific interval, the documentation policy required documentation of focused reassessment at least two more times during the shift for ICUs. Vitals, I&O, Interventions, and device documentation is done in real time/near real time.
20. Basic drains? / Documentation of most drains and tubes has not changed (it is done in site management style like IVs and wounds). Can be located in Skin category.
21. AV fistula? / IV Other
22. Will Pain interventions be shown with assessment? / Use Pain/CDR Tab or ALL DOC to see assessments & interventions together
**Please note if you are giving medications, you do not have to document this intervention. It will be reflected in Admin-Rx, MAR & WIZ orders.**
23. If there is an order for q4h neuro checks, will we chart the neuro assessment q4h? / Yes
24. Fall Risk/Safety: When does this need to be charted?
VUH Falls: / **Falls Risk assessment & status is documented once per shift.**
VCH: Graf-Pif Falls Screen Fall Risk Status are documented once per shift
**Please note q1-2h “Falls Safety check” is no longer required. You will continue your safety rounds, but the documentation by checking the box is not required. As always, document any fall event.
VUH: Morse Falls Risk Screen is documented on admission, following a fall event or significant change in status. There is no longer a “status” field.
25. What exactly is the Medication Assessment? / This is where the nurse uses his or her judgment to review available data from MLT, orders, etc. and determine is the patient has a medication risk. Many patients do have a risk (e.g. Patients on anticoagulants, antihypertensive, chemo, nephrotoxic antibiotics, etc.) But this may not necessarily be a priority problem for most patients. Someone admitted specifically to treat complications from a medication interaction or under-/over-dose, this may be a priority problem.
26. Why did the GI alteration choice go away? / It has been added back
27. Under vascular assessment for edema could there be a way to chart edema without pitting? / Non-pitting is an option:
“Generalized Edema” is no longer available
Use “Other Edema” and annotate as needed
28. Pressure Ulcer Care/Intervention: When you click the done box are you documenting that you did all the things on the algorithm for that stage PU? / The PUPs and Pressure Ulcer Care Guidelines specify that interventions are done as appropriate for the patient.
29. For Re-assessment: If lung fields are clear, but cough still present, do you chart the cough (not a change)? / Choose “unchanged except” and annotate that lung fields now clear. If this improvement were noted near end of the shift, the Patient Response to Care would be another option to note that some aspects of Resp. status improved.
30. Reassessment being located under pain but above all the other assessment fields, why not above pain @ the top of this tab? / Decision has been made to always chart a pain score for the pain assessment/reassessment. You cannot just say unchanged for Pain. (However, Pain reassessment policy does NOT require pain reassessment more than once per shift unless the patient has had pain or a pain intervention – in which case a post intervention reassessment is required.)
31. Where are therapy beds? / Most units’ standard beds ARE therapy beds. For something more than the standard bed for the unit, Skin Breakdown Care drop down options include reasons various kinds of specialty beds are used (for moisture control, pressure redistribution, friction/shear reduction). If bed type annotated, should be done only once when patient placed on bed initially.
32. What is not included in ALL DOC? / Protocols, Point of Care, I/Os, VS
This is to prevent a long loading time for the ALL DOC tab
33. Is Peds Fall Risk is to be charted q shift? / Yes. Chart Falls safety assessment/status qshift. You no longer have to check the box for “Falls Safety Check” qh though. Continue safety rounds & document any deviations.
Per Peds Fall Policy:
Assessments -GRAF/PIF done and documentedin initial shift assessment, with significant change in pt. condition and after a fall. Assessment for pts. At risk for falls in ongoing in semi-continuous fashion but documented only with changes.
Interventions – done as part of falls prevention are documented when performed.
34. Can WEL and OEL be selected as priority problems? / It IS possible to have the assessment of a category be WEL (NOT WNL) but for there to be a priority problem for that category.
Examples:
-Pt. admitted with Cystic Fibrosis and infection for 14 days IV Antibiotics. The reason the pt. is hospitalized is to treat the Resp. Infection 2ndary to her chronic CF and she will always have ineffective airway clearance due to her disease. However, today her Resp. Assessment is completely clear – no abnormal breath sounds, no cough, no sputum. Would document WEL since her baseline will never be “normal” and continue to have Ineffective Airway clearance as a priority problem.
-Pt. admitted following a skull fracture for monitoring for possible concussion. He is at risk to develop a Neuro problem but today, his neurological exam is completely normal. He has no other significant problems. Recommendation is to document WEL for his assessment (since a skull fracture with risk of concussion is NOT normal) and to mark that as significant. It would also be acceptable to identify a Neuro problem and since it might be a risk rather than an actual problem, they could annotate “risk for” if they were uncomfortable documenting and actual problem.
35. What if the assessment category does not need supporting data for OEL or Problem? / Supporting data is not always required for every OEL or Problem. Some “stand on their own” such as Nausea (no emesis, abdomen normal).
Supporting data should be charted if applicable.
36. IAEs: Nurse reported that she charted her assessment and saved it but received an error when trying to save her interventions. / If you change the time before you start charting, this will decrease the odds of getting IAEs.
Using “modify” should eliminate IAEs
If you “overlay” charting fields, you will get IAEs.
37. Will I be able to copy my assessments from shift to shift? / Decision Pending
38. Is it possible to have HED default to exact time with the option to change to collapsed time versus defaulting to collapsed time? / To see charting in actual time, simply click the “Chart” button.
You can also see actual times by using “Show All Result Values”
39. How do you document on a wound/drain/ostomy? / A wound/drain/ostomy are still started from the blue link as before.
40. Does GCS have to be charted on every patient? / No. It should be charted according to unit policy or provider orders. It is a mixed case (not all CAPS) & therefore is not required charting on all patients.
41. Does WEL have to be annotated every time? / ONLY on admission. This is baseline, just like before, it is only required to be annotated on admission & if the condition changes. Use “show all results” to make sure it was annotated on admission (or at least once prior).
42. Can goals be in the same as assessment/problems? / Goals were taken from most frequently annotated goals by RNs in previous charting & will not be changing much. Some may be named differently from the assessment categories, but once you familiarize yourself with the predefined goals, this will be a much simpler process than before.
43. How do I know what goals to set? / Goals should match your 1-2 Priority Problems as indicated in red on the plan tab.
44. Where do I chart ambulatory aides? / Musculoskeletal Interventions:
45. Where do I document diaper change/diaper rash care? / Document appropriate output
Perineal care can be found in:
46. Where do I document hyper/hypotension for BP alteration? / This is a medical diagnosis. Your charted VS will suffice for supportive data for
this problem.
47. Where do I chart sitter at bedside? / Sitter at bedside can be found in Falls/Safety interventions: Suicide precautions or Injury precautions
TIP: If you are unable to find an item, go to the ALL DOC tab & use the “Add” button.
It will help you search to easier locate items.