objectives: hed nursing documentation

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OBJECTIVES: HED Nursing Documentation. Document Interventions, Assessments Set Preferences & Create Assignment View Confirming Med Orders Commit to use HED system safety checks. GENERAL PRINCIPLES OF ASSESSMENTS. Beginning of shift or change level of care - PowerPoint PPT Presentation

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  • Document Interventions, AssessmentsSet Preferences & Create Assignment View Confirming Med OrdersCommit to use HED system safety checksV: training/nurse resident2012*

    V: training/nurse resident2012

  • Beginning of shift or change level of care Items in ALL CAPS on gray bar charted each shiftLine Manage charted each shiftVanderbilt charts to Standards & only denotes variances V: training/nurse resident2012*

    V: training/nurse resident2012

  • Brief synopsis of your shift before Shift change Include major clinical events & information For oncoming RN..does not replace face-to-face reportPrints on OPC as reference for nurse during shift

    Temp controlled with Tylenol. No further nausea. O2 sats improved on nasal cannula.

    V: training/nurse resident2012*

    V: training/nurse resident2012

  • Explore StarPanel.. EMRLook up test results and documents Complete Admission History formAssign a Pathway (Plan of Care) Enter orders in HEO/Wiz CPOEEnter Nursing Orders for New AdmissionV: training/nurse resident2012*

    V: training/nurse resident2012

  • 3 Sections of Admission DataV: training/nurse resident2012*

    V: training/nurse resident2012

  • V: training/nurse resident2012*

    V: training/nurse resident2012

  • PV: training/nurse resident2012*

    V: training/nurse resident2012

  • Processing of Orders Orders & Reqs print to Medical Receptionist (MR) and placed in unit appropriate area MR: Notifies RN of STAT Orders and LabsMR: Notifies Department of Other Tests RN: Acknowledges Orders online Emergency Departments: Order do NOT print. Lab Requisitions generate to printer closest to pts room

    V: training/nurse resident2012*

    V: training/nurse resident2012

  • Steps to Acknowledge OrdersV: training/nurse resident2012*

    V: training/nurse resident2012

    *

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