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Charting a New Course for Patient Documentation

Super User Training

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Upon completion of training, the learner will demonstrate ability to:

1. Share the vision for the changes in nursing documentation

2. Identify at least 2 “Myths” that have been barriers to documentation reduction in the past and verbalize an effective response to both

3. Complete a documentation scenario without assistance

4. Verbalize 3 expectations of a Super User during unit implementation

5. Identify 5 resources available to all staff to support transition to the new documentation processes

6. Demonstrate 3 techniques most likely to be effective in promoting peer adoption of the changes.

What You Will Learn Today

3The Super user role is vital to implementation of this change!

THANK YOU

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Why chart a new course?

Nurses need more time with their patients and to spend less time writing about what they are doing with their patients!

Charting A New Course for Patient Documentation

PUT VALUE BACK INTO WHAT NURSES DOCUMENTWith revisions, need to assure that everything that the nurse is documenting is valuable and

contributes to the patient story and informs the care you and others give.

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FOCUS

Targeted design for the proficient, ethical nurse

Not designed to be everything to everyone

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* Stop documenting MOST normal values

* Stop charting data no one looks at or uses

* Stop duplicate documentation

* Stop transcribing data from devices

STOP!!!

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Myth Busters

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

“If it’s not charted, it’s not done.”

“Quantity of documentation = quality of care I provide”

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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.

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Those making all these changes are out of touch with what really happens

at the bedside- these changes will never work.

NOT TRUE!Many levels of nursing were involved in developing the revisions.

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“Real Nurses” were involved.

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What is NOT changing:

* Care Organizer & Admin-Rx* General format of HED screens and

way to select items from drop down menus or typing annotations

* Nursing Admission History still in StarPanel

* Clinical Care Classification (CCC) standardized terminology for documentation of problems

* Required documentation denoted by ALL CAPS

* Concept of Priority Problems/ goals

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* Pt admitted with complaints of a deep and productive cough for 1 week with progressively worsening yellow phlegm.

* Wheezes present in BLL* Patient is asthmatic* Admission dx is pneumonia* Pt reports hx of asymptomatic AFib X 5 yrs* Patient small stage 1 PU on left buttock * Hypoactive BS* You receive the pt from the ED with antibiotics infusing in r

forearm 20 G PIV* Other than respiratory issues the patient healthy

Patient Scenario

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1. Sign on to CWS w/ your id 2. Click HED train icon3. Use the training patient on your card

The Nit and the Grit of the changes

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New Tabs & Order

• In the training region you may see both the current tabs & new tabs.

• In Live HED, the PLAN tab will load 1st

• Most of the new tabs are in ALL CAPS

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Old VS New Tabs

* Most of the new tabs will be in ALL CAPS but there are some existing tabs that are in ALL CAPS too ( i.e. CRRT) that will continue to be used as we transition.

* There are also some tabs that are used now that will transition over that are not in all caps – i.e Blood transfusion, chemo, Pain/CDR.

* On the chart menu, there will also be the tabs for the areas that are not being implemented in this first phase ( i.e. NICU, OB)

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In Live HED, you will see reduced fields for pain documentation:

Reassessment of pain is documented with a new score Pain documentation requirements have NOT changed,

there are just less fields to document on. Refer to Policy Tech for more details.

Pain Documentation

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Will not be found in the Assessment tab Can be found in Interventions, All Doc,

Pain/CDR, or Admin-Rx New options:

Pain Interventions

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In HED Live, you will see Learner Engagement (session)

Learner Engagement

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New Protocols Tab including CIWA, etc.

Protocols Tab

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Nursing Documentation Guidelines Review

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Tips for ALL DOC

If you can’t find an item, go to ALL DOC & use the Add button to search

The following items can ONLY be found in ALL DOC:• Transfer & transport• Isolation Precautions (or in Interventions)• Co-Sign (for students)• Downtime• Use the “Add” button to search for items in All Doc

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A current shift assessment should be completed prior to discharge, problems needing follow-up should be identified and documented with a plan to address.

Discharge

Discharge Plan of Care Reviewed, Discharge Readiness and Discharge Problems needing follow-up have been moved from the  Assessment/Problem section to the

Plan of Care section on the PLAN Tab & the Education tab.

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When to Document What…

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Currently, most of the documentation is displayed in a real time view. Some spend a lot of time adjusting times they document to be at the top of the hour so the data aligns in a single column, making viewing info easier.With the revisions, the displays of the data has been collapsed to facilitate easy viewing.Data displays in 1 hour increments

VS/I&O Assessment Interventions Pain/CDR Device Protocols

Displays in 12h increments Plan ALL DOCS

Displays in 24h increments Education

Click Chart to see the actual Documentation Times

Display of Data

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Shift to Shift Handovers

Use the Plan tab to facilitate handovers. It should capture the patient story.

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TrainingManager presentation to staffFor Super Users….Attend SU classComplete LMSComplete unit based practice scenarioStaff….LMS Complete Unit Practice. As Super User f/u to see that they have completed and offer help with the unit based practice scenario.

GO LIVE

Oct 13th Adult Acute Care Group 1 (7N, 7S,, 6S, 5S)Oct 20 Adult Acute Care Group 2 (10S, S34, 44, 64, 74; CRC)Oct 27 Peds Acute Care ( Inpts; 6th & 7th floors)

Nov 3 Adult Acute Care Group 3 -(11N, 9N, 9S, 6N, )Nov 11 ICUs Group 1 (PICU, PCICU,  10N, 11S, 5N) ** NOTE ON WED**Nov 17 ICUs Group 2 (CCT 8,9,10 )

Dec 1 ICUs Group 3 (S54, COBS, 6 7 CCT)Dec 8 ICUs Group 4 (Adult ED, CTU;  Peds ED)

( Excluded: NICU/ Newborn Nursery, VPH, ED, OB, Periop and procedural areas & areas that don’t document in HED)

Support

1 Super User each shift on each unit for the first week

SSS 24X7 for 5 days (covering multiple units)

Round and assist staff**Review charting **Trouble shoot

Training and Implementation

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GO LIVE DAY Tech team will push the new tabs to HED

“LIVE” by 0700 Day shift will begin using the new tabs To view previous charting, toggle back to

the “old tabs” from the tabs drop down menu or via the chart option in the top tool bar

Transitioning from Old to New

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Expectations of a Super User during unit implementation:

Role & Responsibility

“At the Elbow” Support to Nursing Staff ( answering ?s and coaching)

Review Documentation via chart audits and follow up with users for any issues

Report problems/Issues Roll model completion of

ALL 4 LMS modules and Unit Practice Scenario

Follow-up with staff assigned to you to encourage and track completion of LMS modules and Unit Practice

Communicate to Manager any concerns about readiness of staff assigned to you

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Resources

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Resources available to all staff to support transition to the new documentation processes Hover Overs/ Links in HED (Krames)/ Mosby Nursing Documentation Policy Job Aide Super User Guidelines for Nursing Documentation Support Systems Support Nursing Education Website FAQ Debriefing sessions Colleagues on the documentation committee/SSS/Educators Help DeskWhat Else???

Resource

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Online Resources

Click icon on desktop or link on VUMC webpageType SSS in main VUMC webpage

and select System Support Services to get our webpage.

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Demonstrate 3 techniques most likely to be effective in promoting peer adoption of the changes. Timing Approach Follow-up

Promoting Adoption

TAKE CARE OF THE PATIENT, then worry about charting!

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Would you approach a nurse or staff member in the following situations? In the break room? At the accudose machine? Two nurses discussing the upcoming weekend? A care partner running with a crash cart? A nurse near a room with visibly upset family? A nurse providing care?

Timing Is Everything…

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Coach/ mentor – non punitive “ I am touching base with all RNs to see how

charting is going with the new system. It’s a big change and I am here to help. What did you think? Did you have any questions or concerns.

Then give feedback… I noticed “…..” Do not give a huge list of issues- prioritize It will take a lot of coaching and practice

Approach

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More Direct Phrases to add to your collection “Can you tell me a time when I can come

back?” Check with charge nurse for best times to

return considering typical unit workflow patterns

Approach (cont.)

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Denote all ?s/Concerns and seek out answers Prioritize Investigate Triage

Follow up

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What’s wrong with this picture??

• Only chose 1-2 Priority Problems

• Only set goals for those 1-2 priority problems

• Chart ALL categories on admission

• Annotate WEL on admission

• Make sure there is supporting data for OEL

• Is it WEL (baseline) or OEL?

Admission Assessment

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What about “difficult” users

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Do’s

Strategies

Don'ts

• Be comforting not confrontational. • I know it’s hard and it takes more time

right now. • I understand your frustration.

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I am responsible for getting this fixed, and for documenting the problem and its solution.

I understand that people are frustrated and angry, but I won’t take their anger personally.

I will empathize with the frustration that my peers feel, and tell them that I understand and share their feelings.

I will calm them down with my words and manner.

I will not accept abuse. I will not blame the user.

Repeat after me….

SUPPORT CREDO

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Complete the LMS modulesComplete a Unit Practice ( on your own) From your manager/educator, get list of staff

you are coaching (approx 10)Communicate to SSS any concerns or

questionsPLAY in HED train

Next Steps