Tip Sheet Template - PIVOT · Web viewDocument a T imeout before procedure begins, specifically before any medication is given. All members of the team participate to ensure correct

ClinDoc Tip Sheet INPATIENT SEDATION NARRATOR

DESCRIPTION/BACKGROUND

New! LIVE 10/20/2020 Audience: Critical Care Nurses assisting in bedside procedures for patients receiving moderate sedation/analgesia for therapeutic, surgical and/or diagnostic procedures.

CONTENTS

Inpatient Sedation Narrator................................................................................................................................................ 1

Description/Background.................................................................................................................................................. 1

Your Workflow..................................................................................................................................................................... 1

Getting Started................................................................................................................................................................. 1

Adding Staff...................................................................................................................................................................... 3

Pre-Procedure Documentation........................................................................................................................................ 3

Procedural documentation.............................................................................................................................................. 5

Medications....................................................................................................................................................................... 5

Additional Tools............................................................................................................................................................... 6

Post-Procedure................................................................................................................................................................. 7

How Frequently Do I Document, and What?.................................................................................................................. 7

Editing Documentation.................................................................................................................................................... 7

Provider Documentation.................................................................................................................................................. 8

YOUR WORKFLOW

GETTING STARTED

1. Open the Sedation Narrator. This can be found under your more menu to the right of your activities tab (A), or searching for “Sedation” in the upper right corner of your Epic screen and choosing the “Jump to” option (B).

© 2019 Epic Systems Corporation. Confidential. © MLHS. Last revised 9/11/2023

1

ClinDoc Tip Sheet

2. Click Documentation Start. Verify that the date and time, which are auto-populated from the time you clicked, are correct. Click Accept. “Documentation Start” simply allows you to add members to your procedure and complete baseline/pre-procedure documentation.

3. Use the quick buttons on the right side of your screen within the Narrator to document, working from top to bottom.


2

ClinDoc Tip Sheet

ADDING STAFF

1. Click the to open up a section of documentation.

2. Add the staff present for the bedside procedure. a. Staff already signed in to the patient’s treatment team will show up as quick buttons. b. For staff not listed, search by clicking then use the magnifying glass to search for and add

another staff member.


3

ClinDoc Tip Sheet

PRE-PROCEDURE DOCUMENTATION

1. Click the button to review and verify that the provider has completed the appropriate pre-procedure screening.

2. Complete the Pre-Sedation Checklist, Baseline Pain/LOC, & Baseline Respiratory Status.


4

ClinDoc Tip Sheet

3. Complete baseline vitals - once validated in the flowsheet activity they will populate in the narrator. Navigate to the Vitals Flowsheet by either using your Flowsheet Activity button at the top of your screen or the

link on the right sidebar of the Narrator.

PROCEDURAL DOCUMENTATION

1. Document a Timeout before procedure begins, specifically before any medication is given. All members of the team participate to ensure correct patient, correct procedure, and correct site if applicable.


5

ClinDoc Tip Sheet

2. Click Procedure Start when the provider is ready to begin, verifying the correct date and time auto-populated, and click Accept.

MEDICATIONS

1. Locate the desired med on the left side of the Narrator, under the MAR. The Narrator MAR is filtered to only show meds from the MAR that are applicable to being given during a bedside procedure. Also, pyxis override pulls will show, highlighted in pink as they normally do, if they fall under the filter.

2. Scan your patient and use MLH’s Red Rule to confirm name and date of birth.


6

ClinDoc Tip Sheet

3. Update the Administration window to reflect the exact dose that was administered. Epic may give you an “Expected dose” warning –if this is the dose requested to be given by the provider at that time, the message can be ignored.

4. Chart each dose individually, each time the medication is given.

ADDITIONAL TOOLS

In the left sidebar there are additional functions you may need to access quickly during procedural sedation:

Acknowledge Orders (a) Specimen Collection (b) Blood Navigator (c)

POST-PROCEDURE


7

If necessary, the nurse can administer a med from the MAR. Additionally, a request can be submitted to have missing meds added to the filter through the Help Desk button in Epic or ServiceNow.

ClinDoc Tip Sheet

1. Document the Procedure End date and time using the button on the right sidebar and click accept. This indicates that the procedure is complete, but you will still be monitoring and documenting on the patient.

2. Document pain, LOC, and an Aldrete score immediately post-procedure and every 15 minutes x 2 (timed from the last dose of medication).

3. Complete all components of Post-Procedure Documentation and Procedure Outcome. Clicking completes the sedation event log for the procedure and allows the provider to sign off on

the documentation.

HOW FREQUENTLY DO I DOCUMENT, AND WHAT?

Documentation frequency requirements: Baseline - vitals, level of consciousness (LOC), pain, & respiratory status Immediately prior to any medication administration - vitals, level of consciousness (LOC), pain, &

respiratory status Every 5 mins during procedure - vitals Every 15 mins during procedure - pain & LOC

EDITING DOCUMENTATION

If you need to make an adjustment documentation in the Event Log, simply hover over the area, click to edit, make your changes, and then click Accept.

You will not be able to edit the time that the information was documented. If you need to edit time, you must delete the documentation and re-enter with the correct time.


8

ClinDoc Tip Sheet PROVIDER DOCUMENTATION

After nursing documentation and post-procedure vitals have been completed, the provider must sign off on the procedure. This can be done from the nurse’s screen, choosing Sign Off and then the provider will enter his/her password.

Additionally, the provider can log in independently, navigate to their inbox, and sign off the procedure.


9

ClinDoc Tip Sheet


10

Documents

Tip Sheet Template - PIVOT · Web viewDocument a T imeout before procedure begins, specifically before any medication is given. All members of the team participate to ensure correct