Horizon Expert Documentation VUH Emergency Department

Horizon Expert DocumentationHorizon Expert DocumentationVUH Emergency DepartmentVUH Emergency Department

Learning Objectives Identify workflow changes and processes that remain the same (i.e. order tracker, trauma documentation)

Locate and document assessment and interventions for Adult ED patients

Demonstrate use of HED to record care under the Adult ED Hourly tab

Verbalize understanding of the changes in documentation and workflow associated with new Falls/Safety HED build

For Admitted Patients, assign a plan of care in Starpanel, using a diagnosis specific pathway if available, or if not using a generic pathway.

Identify standardized priority problems, patient oriented short term goals, document an end of shift nursing summary and plan for next shift


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What’s changing, what’s not

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Changing to HED Not Changing

Triage process X

Trauma patients X

ED patient assessment Use Adult ED tab instead

of StarPanel Nursing

Assessment

Hourly documentation Use Adult ED hourly tab

instead of StarPanel

Nursing Assessment

Med Administration X

Planning and managing

care

Priority Problems for

Admitted Patients under

plan of care tab in HED,

save pathway to

StarPanel

Falls

assessment/documentati

on

Use Falls Risk/Safety

documentation in HED

for both ED and Admitted

patients. Will no longer

be in Social screening

form.

Stroke & STEMI

documentation

X

(paper form

now scanned)

New Patient

Scenario:

Jane Doe, 58 y/o female with history of hepatitis, HTN,

and anxiety brought into ED by family for c/o

shortness of breath which has been going on for about

a week but worse today.

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Practice ScenarioScenario: Patient brought to room C27 by wheelchair, ED property record

completed. Patient complains of shortness of breath with exertion and anxiety

Vital signs 98.1 oral, Pulse 101, RR 20, BP 170/95, O2 sats 88% on room air, placed on 2L nasal cannula

Airway is patent. Dyspnea on exertion. Lung sounds are CTA. Skin is warm, dry, and normal color. Mucous membranes are moist and

Cap refills is less than 3 seconds Heart rate is regular and pulses are 2+ Eyes open spontaneously, verbal response is oriented, and motor

response obeys commands. Pupils are 4 mm and react briskly Complains of pleuritic pain. Rates as 4 on 0 to 10 scale. Pain is sharp

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Practice Scenario

Interventions:

18 gauge PIV inserted in right cephalic vein on first attempt

Urine and blood obtained and sent to lab

Patient sent to ultrasound via stretcher with transporter

Plan of care: MD evaluation, medications, observation,

diagnostic procedures & teaching

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Adult ED Hourly Tab

Scenario – Patient comes back from ultrasound and a brief assessment is

done Respirations are even and nonlabored Skin is warm and dry Resting with eyes closed. Opens eyes to speech, verbal

response is oriented, opens eyes and follows commands. Patient complains of lower back pain and rates pain 9/10. MD

notified. Patient repositioned with pillows Dilaudid given for pain, documented in Order Tracker

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Learning Objectives Identify workflow changes and processes that remain the same (i.e. order tracker, trauma documentation)

Locate and document assessment and interventions for Adult ED patients

Demonstrate use of HED to record care under the Adult ED Hourly tab


For Admitted Patients, assign a plan of care in Starpanel, using a diagnosis specific pathway if available, or if not using a generic pathway.

Identify standardized priority problems, patient oriented short term goals, document an end of shift nursing summary and plan for next shift


8

HED Changes with Safety/Falls

New Safety/Fall Risk documentation:

1. New evidence-based Morse Falls Scale

2. Updated Safety and falls assessment sections

3. Restraints documentation simplified

4. New Education tab to capture specific topics and

caregiver(s) contact information

Morse

Scale

Restraints

Education

Falls/Safety Documentation now in HED

Scenario-

Complete Morse Fall risk screen:• Patient has not fallen in the last 3 months• Patient has multiple diagnoses• Uses a cane• Impaired gait• Has IV access• Knows own limitations/abilities

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Priority Problems Documentation in HED

v:training/neo/rn/2011/day1 11

Priority Problems for admitted/observation patients

WHY?

We all have different ways of describing or talking about problems. You call it pain, I call it alteration in comfort

The decision was made to standardize how we talk about nursing care. The Clinical Care Classification* (CCC) Saba Model was selected

The Clinical Care Classification (CCC) System* is a standardized, coded nursing terminology that identifies the specific elements of nursing practice

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Priority Problems: What to Do & When


Choose the pathway that most closely reflects the expected patient progression. Usually the reason for admission. Specific pathways will have phases, goals and interventions that are a better fit. The evidenced based pathways can better guide care.

Medical Pathway – Pneumonia1. Admission – Orders & interventions are aimed at achieving stabilization (improving airway

clearance by suctioning, O2, antibiotics, . . .)2. Stabilization - achieving controlled symptoms (fluid excess control, med mgmt for patients with

chronic conditions)3. Discharge – Ready for self-care; or care by another caregiver

Admission•Select & Save Pathway (StarPanel )

Admission

•Document Pathway Phase (HED) •Create 2 Priority Problems (HED)

Definitions are located under “links” in HED.

Potential priority problems for Jane Doe:

1. Pain2.Falls Risk3.Airway Clearance

Goals should be patient specific and measurable

Such as “Pain less than 4 on a

scale of 0-10”

Nursing Summary

Chart a brief synopsis of your shift before Shift change

Include major clinical events & information

For oncoming RN but does not replace face-to-face report

Prints on OPC as reference for nurse during shift

Plan and Priorities for Next Shift Your recommended plan and priorities for the oncoming nurse to address

Think of it as a “to do” list for the next RN

Keep it brief-240 character limit


Horizon Expert Documentation VUH Emergency Department

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