electronic controlled drug record (cdr) in. at the end of this tutorial, the nurse will be able to:...
TRANSCRIPT
Electronic Controlled Drug Record (CDR)
in
At the end of this tutorial, the nurse will be able to:
• Identify the need for electronic documentation of IV controlled medications
• Summarize process for the documentation of and cosignature requirements of IV controlled substances within HED
• Identify processes when paper CDR will still be required
Need for Change
• CDR documentation practices varied across units – need for standardized approach
• Corrections needed to CDR were time consuming and disjointed – nurse may not be working or available to make corrections
• Auditing and review process in electronic medical record left room for improvement
What’s Changing
• Blank CDRs will no longer be available in AcuDose with meds. CSLs will have in locked drawer
• 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
Don’t forget to Co-Sign!!
Start Infusion*Also used for new bag
1. Enter dose of med and rate
2. Enter concentration found on drug label and select started
3. Enter volume primed – HED will auto calculate a left to count
4. Have RN cosign at bedside
Drug Label
The drug concentration to be entered in HED can be found on the medication label.
Locate priming volume on packaging of IV
Charting Specifics
Chart every 4 hour charting (or per unit standard): Dose & rate and Intake
Chart hold status: Note when a medication is being held and why
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
1. Enter concentration from drug label and select “stopped” from dropdown
2. Use last “left to count” number and enter this as “Volume to Start”
3. Enter “volume wasted” – HED will auto calculate a left to count
4. Have RN cosign at bedside all of the fields
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.
• 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– When receiving patients from Anesthesia providers, it is
acceptable to cosign with licensed RN on unit
• 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
RacfID is required to co-sign in real time.
Co-Signing
When & Where to Cosign• When
Starting/Ending new bag on unit – HED Change in caregiver in SICU
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 do not know your RacfID or password, please call the Help Desk at (3-HELP) to have your RacfID password reset prior to the pilot.
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
Effective December 2, 2014
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)
Start
• Drug, dose, concentration, start volume, primed volume entered. Co-sign required.
New Bag, Rate
Change, Hold
• Correct 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 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.
Tip Sheet – Print and Keep