Electronic Controlled Drug Record (eCDR)

in

eCDR Overview

Controlled Drug Record documentation will be completed in HED instead of on the paper CDR.

• Paper CDR will only be used for transfers into or out of areas not using CDR in HED or during downtime.

• Epidural infusions will remain on paper CDR at this time.• New CDR tab in HED.

Palliative Care Pilot

8/12/14

Burn & PICU Pilot

9/23/14

SICU & 9S9/15/14

VCH 6A1/20/15

VUH Towers2/10/15

VCH2/24/15

eCDR Timeline

Jan ‘15 Feb ‘15 Aug ‘14 Sept ‘14

2014-15

CCT, MCN & 4E

2/17/15

Don’t forget to Co-Sign!!

Start Infusion

Drug Label

The drug concentration to be entered in HED can be found on the medication label.

Locate priming volume on packaging of IV

Don’t forget to Co-Sign!!

New Bag/Syringe

Charting Specifics

Annotate if Left to Count is not zero:“Wasted amount measured &

witnessed by 2 RNs as per protocol”Don’t

forget to

Co-Sign!!

Stop Infusion

Don’t

forget to

Co-Sign!!

Reminder: Clear pumps at the end of each shift or per unit standard

*When reporting to another area using HED CDR

End of Shift/Handover Report

During handover report the nurse should chart volume at start and cosign.

RacfID is required to co-sign in real time.

Co-Signing

What’s Changing

• Blank CDRs will no longer be available in AcuDose with meds. Call pharmacy if a paper CDR is needed

• Documentation of all requirements elements will be under new CDR tab in HED, including cosignature

• For areas, not using HED CDR documentation, paper CDR will be used in handover

• Assessment of patient under sedation or on pain medications

• Documentation of the following will still take place in HED: – IV Intake– IV drip rates

What’s NOT Changing

NEW

NEW

When & Where to Cosign• When

Starting/Ending new bag on unit – HED Change in caregiver

End of Shift/Bedside Report

Transferring patient to unit using CDRReceiving patient from units using CDR

• WhereCosign in HED

Cosign in HED

Cosign in HED

Cosign on CDR and annotate See CDR

• If you receive a patient with a paper CDR, follow the Start Infusion instructions using the CDR amount as Amount at Start.– Annotate “See HED for CDR documentation”– Paper CDR should remain in the chart & be scanned into EMR

• If you transfer a patient to another area, you must transcribe Left to Count from HED to the CDR. – Annotate “See HED for CDR documentation”– Paper CDR should be given to the transfer unit

Transfer to area not using HED

CDR Tab

If you do not know your RacfID or password, please call the Help Desk at (3-HELP) to have your RacfID password reset prior to implementation.

If you want to have the same password for both your VUNetID ePassword and your RACF ID, follow these guidelines:

The password must contain exactly 8 characters It must have at least one capital letter It must have at least one number It cannot have any special characters or be a part of your name, SSN, user ID, or date of birth. Example: Coconut1

To reset your VunetID password click the following link: http://its.vanderbilt.edu/epassword/

RacfID Password Reset

System Support Staff will be providing 24/7 onsite support.

If you have questions or need assistance: Call the Help Desk at 343-4357 (3-HELP)

VUH Tuesday 2/10/15MCN, CCT & 4E Tuesday 2/17/15

Start

• Drug, dose, concentration, start volume, primed volume entered. Co-sign required.

New Bag, Rate

Change, Hold

• Correct patient, drug, dose, concentration, infusion rate & pump settings verified by 2. Co-sign required.

Q4h• Amount infused (dose, intake, volume @ start, volume infused). No co-signature needed.

Handover/

Change of Shift

• Correct patient, drug, dose, concentration, infusion rate & pump settings verified. Pump cleared q12 h. Co-sign required

End • Drug status: “stopped”; volume @ start, volume wasted. Co-sign required.

Transfer from/

to Paper CDR area

• Sending to paper CDR unit: transcribe “left to count” from HED to CDR & send paper CDR to receiving unit. Note “See HED for CDR documentation” on CDR.

• Receiving paper CDR: follow “Start” instructions above; place paper CDR in paper chart. Note “See HED for CDR documentation” on CDR.

Process for Controlled Drug Record Charting in HED CDR Tab