SUPER AND END-USERS
1. Today through
Saturday July 12 0700-1900, there are representatives from Elsevier in the
hospital who are here to help with the CLINICAL PRACTICE GUIDELINES (CPGs), PLAN OF CARE,
PATIENT EDUCATION, ASSESSMENT DOCUMENTATION, and INTERVENTION documentation.
It was very helpful to have someone explain the care plan documentation process
again and what we should be doing with that mixed up thing. If you have
time, they can be reached at Simon Pager number 12792. The Super User of
the day should really try to get the rep to come teach you so that you can help
others that cannot meet with the rep (i.e., night shift). Am I a pro
now? No, but it helped some. They stated that we should only be
spending about 2 minutes on the Care Plan. Laugh now.
2. Nursing Notation:
Still some questions coming up related to Nurse's Notes. There
are three good ways to chart these, depending on what's going
on with the patient.
A. Team Chat: found in
the Overview Report. This is the "yellow sticky
note" and is fairly informal documentation. You can use it to
pass on things about the patient to the MDs, RNs, treatment team.
B. Care Plan: We definitely should not be using the NOTES Activity to
chart nursing notes (I verified this with several EPIC CTs today).
Use the CARE PLAN. I
know this seems like a strange place to document but according to the Epic CTs,
this is similar to the "MISC" notes section we used in McKesson.
Let's say your patient
leaves the floor to go to CT or wherever and you want to document that you took
the respiratory bag, the code drug box, the ambu bag/O2 tank and the transport
monitor on the road trip. You do this in the Care Plan Activity.
Go to the General Care Plan (for
us the newborn/infant/pediatric General Care Plan) and expand it to show
the Plan of Care
Review goal (green dot). Click on Document. You
can then free-hand a note in that bottom section or use smart text.
You should also use this
same procedure to document (at the end of your shift) that you reviewed the Care
Plan (according to the Elselvier rep today). They want us to
write a note at the end of the shift that "synthesizes" or kind of
sums up the documentation that you did for each care plan goal (basically 1-2
sentences on the outcome of the shift care).
Finally, when you chart
a note within the Care Plan and are finished with it, you can then go to
the NOTES ACTIVITY, choose the PLAN OF CARE tab up top and
you will see your note in the list.
C. On most cells in the Doc Flowsheets, if
you highlight the cell that you'd like to write a note on then right click the
mouse, NEW
NOTE will appear. Choose this and you can write
a short note related to that whatever in entered into that cell (it gives you
more characters that the "comments" field). You might remember
that this is where you can "Insert Data" into your note
if you'd like. When you are finished writing this note, it also will
appear in NOTES
ACTIVITY, but instead of the Plan of Care tab like the previous type
of note, it will appear in the NURSING
tab up top.
3. Charge
Nurses: Epic people are working on a solution for you to be able to
filter our OR patients out of the gigantic OR schedule. I know it was
"fixed" last week, but it was broken again today. I will update
you when I know more.
4. Observations
and Treatments: we all know it's been difficult to go ALL OVER THE
PLACE to chart the things that were in Observations and Treatments section of
McKesson. This issue has been raised to the Epic folks, let's hope we get
it all back under one roof for ease of charting. If you've compiled a
list where everything is located and would like to share, send it to me and I
will put it all together.
5. Until we are
able to document WAT (Withdrawal
Assessment Tool) scoring and SBS (State Behavioral Scale) in
Epic, we should be documenting these scores on paper. I have made several
copies of each sheet and placed them in the appropriate place on the file
folder wall thingy behind the charge nurse desk.
6. I submitted another
request for them to add a ROW under the ETCO2 or some other way under the Oxygen Therapy heading for
nurses to document Nitric
Oxide easily on the Pediatric VS complex flowsheet.
7. At the end of
your shift, please remember to unassign yourself from the treatment
team. You can do it by right clicking and "end my assignment".
I also happened upon another option that may work
automatically the end your assignment at the end of the shift. Go to
the Overview report
for your patient. Click on the TREATMENT TEAM hyperlink. In the
middle of the page, there is a heading that says Treatment Team and
then two boxes that say Search
for a Provider and Search for a Provider Team.
If you click the green plus sign beside Add Me, you will see
a box appear that says New
Provider with your name and a start/stop date and time for your shift.
Try this and see if your assignment ends at the end of your
shift. Don't know if it'll work but we'll see.....
:) Cheers.
ABG
Melinda would like to add one more thing brought up by Gregg today.....
Please remember to go into LDAs to D/C any LDA that is no longer applicable. For example, if you extubate to 2LNC, you need to end the ET tube as airway. This is also critical to do for central lines, foleys, and PIVs as they will continue to carry over if not discontinued. Moreover, it will eventually distort our line days data collection for VPS and our infection rates.
Thanks so much for all your hard work and patience. Thanks ABG for this great list of hints!!
Melinda
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