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Nurse Resident 2012 Training ID: TRAIWIW… NURSE 1. 4 hour classes a. July 16: 2 Adult Classes : Monday 0730-1130a 1010 OH and B319 b. July 17: 2 Adult Classes: Tuesday 0730-1130a 407 OH and B319 c. July 13 Peds: Friday 8a-11:30a d. July 13: Peds: Friday 12:30-4:30p Supplies Playback RN orders: TRAIAKO Before class Trainer’s Manuals: (2) in B319 (2) in 407 OH and (2) 1010 OH Wireless Scanner for Trainer (1)in each training room Rosters with column to check “Passed boards” Handouts: Guided note-taking sheets Laminated POS and Lab Req - – can share Take Home Tip Sheet Setup: 1. Amanita: o Job Title: RN … Role: Nurse o Dept: Other o Lookup, change, acknowledge o If boards not passed after class, change Amanita to MR, Other… use roster during class to check who just passed board… then verify in database 2. Acudose – RN change to non-clinical if don’t pass boards 3. Armband and PMM - given access to final unit at Match time LCD Slides: (ALT/ESC to Toggle) 1. Objectives HED 2. Principles of Assessment 3. Nurse Summary 4. Objectives HEO/Wiz and StarPanel 5. Admission History Sections 6. Flu Vaccine 7. HEO/Wiz Legend 8. Processing Orders 9. Steps to Acknowledge Orders Access: RN but if have not passed boards change to Title: Nurse Residents, Role: MR/other. Acudose 5/7/2017D:\769836827.doc – Non Clinical, PMM as Float pool 1 Before Class starts… 1. Rosters: Ask question …” Have you passed boards” to the people not listed on Roster as PASSED. Update roster and check data base to confirm did pass before changing amanita 2. Open PPT slide displaying Class Objectives Introduction Trainer: Welcome to Clinical Computer Class Training, taught by our department, Systems Support Services. A. My name is ………. B. Restrooms are…. C. Length of class is 4 hrs, with a break Objectives for today are….( PPT Slide 1) HED Care Organizer, HED, Admin-RX OBJECTIVES: HED Nursing Documentation LCD Slide 1 Document Interventions, Assessments Commit to use HED system safety checks Set Preferences & Create Assignment View Confirming Med Orders Commit to use HED system safety checks Trainer: HED (Horizon Expert Documentation) is the nursing documentation system. There are 3 sections to HED that will be discussed: documentation of Interventions/ Assessments, Care Organizer, Admin-RX which is bar code scanning of med and Engage Learners and acknowledge past experiences: “Who has used an electronic nursing documentation? Anyone used HED? At Vanderbilt or elsewhere? Who has done Bar-code Scanning of meds? Did you like it”? 5/7/2017D:\769836827.doc 2 Brief overview of Screensaver This is a HIPAA-compliant screensaver view of the Inpatient WB that displays on CWS. The columns are Bed, Patient Name displaying only initials, Age, LOS. The Status Column displays the admission type. IA is an Inpt admission and OT is an Observation Admission. The PB column defines the patient's status for release of information. The Attending column displays the admitting attending. The Orders column displays with red and blue boxes alerting the nurse that there are orders to be acknowledged. Red= STAT Blue= standard Links to flowsheet, MAR and labs The screen prompts the user to press the spacebar to log on TRAINER: Sign-On. Note StarBrowser displays in lower tool bar ... this is StarPanel, the electronic med record system. We will cover this later in class when reviewing this application. Click on the Go To Desktop Icon from StarBrowser Double-click on the HED TRAIN. Care Organizer – used to identify your patient assignment for the day and what meds to give hour by hour. This will be covered in the scanning portion of the class. Find the patient from the laminated sheet and click on it and Click HED 5/7/2017D:\769836827.doc 3 HED Documentation Main Screen Quick overview Pt name- click on down arrow to see full census Allergies are imported from HEO/Wiz Scanner Reset is used for resetting med scanner Links: to additional resources such as Micromedex What’s New in HED Review tab for review of documentation Tabs: Training computers have all tabs for all units. You will only see the tabs for unit you are working on for current rotation Additional Tabs: click the upside down triangle with double lines to see additional tabs Left Menu Bar: use to navigate charting area VUH VS I&O tab always opens first Click “Show ALL” – Jump to INTAKE section, then Jump to PAIN. Notice documentation area to the right jumps to that section. Left bar: Note also under VS / I&O tab: Vents, Med Drips, CTs, Wound Vacs Vertical Column and Previous Documentation Note DATE and TIME of column and white boxes to chart in Click Cancel at bottom Scroll bar on Right side for up and down Arrows for back & forward in time. New Admission Scenario: Billy Bob’s O2 sats were 89 % on room air and O2 initiated at 2L. He arrives on your unit, complaining of nausea and pain. 2 IVs are infusing to CVC: Heparin drip and D5 ½ NS with 20KCL. He was given codeine for pain prior to transfer and vomits dark green emesis into a towel just as he arrives on the unit. 5/7/2017D:\769836827.doc 4 Vitals / I&O Tab 1. Click VS on left Bar 2. Click Chart 3. Click SHOWALL next to ADD to display all items in the VS category 4. Change time to 30 min ago: Double click or use arrows 5. Click Temp # 1 in F. Type 101.4 oral 6. Click oral from the drop down box 7. Click exclamation point. Highlight value in red; significant finding 8. Click heart rate/DAS. Type 112 9. Click Apical from the drop down box 10. O2 Sats: 93%....On Oxygen 11. O2 Liter flow: 2L…Nasal Canula 12. Scroll to IV Site Check: add How often are IV sites checked? Peds is every hour, Adult every 2h. Site assessment done every shift 1. From Left Bar, Click Pain 2. Click Show ALL next to ADD 3. Pain Site: chest 4. Pain Description: Aching/constant 5. Pain Scale: numbers 6. Pain Score: 8 7. Pain Goal: 3 8. Pain Intervention: see MAR and emotional support When should pain be reassessed after an intervention…in this case 5/7/2017D:\769836827.doc 5 medication and support? Within 2 hrs– Frequently missed and Vanderbilt is cited/ fined. Note “Response to Intervention” tab. Do not chart response and intervention at the same time. Document 300ml D5 ½ NS with KCL, Emesis (O) with note of small green amount 1. Click Intake on left bar 2. Click SHOWALL next to ADD. Note Oral is listed first 3. Scroll to D5 ½ NS with KCL: 300 4. Add Comment: Infused in ED 5. Click Output on left bar 6. Click SHOWALL in next to ADD 7. Scroll to find Emesis (O) 8. Type (1) Occurrence, unable to measure 9. Annotate with sticky note details, i.e. small amt green Yellow check mark indicates unsaved data. Click Save 10. Review data entered, time and date. 11. Click Confirm Trainer: Note I&O summary in LEFT bar. HED displays shift and 24 hours. Trainer: Monitored VS/DAS = Downloads VS from bedside monitors. You will learn how to on unit Blood Transfusion Demo Only Trainer: Click on the upside down triangle with double lines to add the Blood Transfusion tab to your view Review only Consent and Teaching section at the beginning Scroll to view various blood product categories, PRBC, platelets… 5/7/2017D:\769836827.doc 6 Unit # on TAR – Product verified with 2 licensed personnel – Trainer: checkmark this Infusion status…. Started, etc Special Equipment Trainer: Click save and point out that confirm screen is ideal way to cosign blood products. (But will practice how to cosign after the fact later in class with Insulin.) Where are VS documented? VS or Blood Transfusion Tab. Documenting one place will display in the other Assessments and Interventions 5/7/2017D:\769836827.doc 7 LCD Slide 2 Assessment Principles Beginning of shift or change level of care Items in ALL CAPS on gray bar charted each shift Line Manage charted each shift Vanderbilt charts to Standards & only denotes variances Systems Assessments Click on the dropdown triangle and add Med/Surg/Assessment Intervention Tab Click SHOWALL on Left Bar Click CHART and Change time to 0730 Click Neuro, click show all: Document Standard Met Click Cardiovascular, click show all: a. Standard Met Except b. Click drop down for Pulse: Standard display in ALL CAPS as Regular & 60-100 BPM. Here’s where you find standards for each assessment c. Click Edema site #1 d. Edema location: BLE – add comment “ankles” e. Edema scale 1 + pitting f. Scroll to Telemetry alarm settings – must enter / won’t download Click Pulmonary/respiratory: click show all a. Click STANDARD MET EXCEPT. Standards in ALL CAPS b. Click RLL & select fine crackles c. Click LLL & select fine crackles - If make a mistake, click again to deselect d. Click cough 5/7/2017D:\769836827.doc 8 e. Click productive f. Secretions: Make up some nasty secretions! g. Incent Spirometer: (600 X 5) Scroll to Pulm Intervention: D B & Cough and NT suction Trainer: Most interventions at end of systems section Renal/Urinary: Document Skin: Review section only Standard Met Trainer: Note skin assessment done here, checkmark Braden score documented in WIZ/HEO. This will be reviewed later. Falls risk: Review section only Everyone is at least STANDARD risk. “Any 1” or “Any 2” factors will designate HIGH risk; also 4 Meds Be sure to complete FALL RISK ASSESSMENT portion for everyone Line Management CVC: Scenario Dr. Golightly inserted the triple lumen in the ED. Document the CVC with information you know. a. Click CVC from Left bar b. Click Start New CVC Site c. Line Type: Central Line d. Site: Internal Jugular e. Side: Right f. Lumen description: proximal, distal, middle g. Dressing: Chlorhex Drsg, Transparent h. Secured With: Sutures i. Type “T” in Date and Time to insert current date and time. Can change j. Inserted by: Dr. Golightly k. Location: VUMC ED 5/7/2017D:\769836827.doc 9 l. Response: c/o pain on insertion, site comfortable after procedure m. No comments n. Click “Save” Site Assessment: Note Boxes to document site after Line information… a. Proximal Lumen Status: Intact, patent, flushed no resistance (address each lumen as appropriate for real pts) b. Proximal Lumen Fluid/Med infusing: D5 ½ NS with KCL c. Site Appearance: Dry & warm d. Surrounding Skin: Dry & Intact e. Site Dressing: Dry & Intact f. Click Save and Confirm Discontinue IV: Click on magnifying glass. Review section only. When ready to discontinue the CVC, just click on the ICON and complete lower section. PIV, wounds and urine catheters work in the same way. Interventions 1. Click Chart and Show All 2. Activities of Daily Living: under Hygiene a. Mouth care b. Bed Bath 3. Nutrition by Nursing – point out only 4. Procedure on Unit: a. Documentation of procedures on unit, such as chest tube placement b. Codes are documented on resuscitation record on crash cart. Click box if code… “on resuscitation record” 5. Click Save and note option to change time here as well and buttons in lower right 5/7/2017D:\769836827.doc 10 Trainer: Notice different options: Save and Confirm = save data Save and Chart new = saves current data and opens chart to current time Continue = returns to previous screen – can change current charting Discard All = exit without saving- ie wrong patient ALL Click SAVE & CONFIRM COPY Is there a way to copy your previous documentation and change only what is different? Yes 1. Click Assessment/Intervention tab 2. Chart must be CLOSED, Click in space between date a time 3. Click copy from the drop down box Trainer: Data pre-fills new med time column. Change one thing about your assessment and save. Remember, the Entire column is copied so make changes to copied data based on reassessment. Change Pulmonary Assessment from fine crackles to coarse crackles. Save and Confirm. What data can’t be copied? Numerical data Annotations/ comments Other people’s data Into the future After 30 hours… so it works for same assignment multiple days All or nothing, but remember you can edit what you copied. 5/7/2017D:\769836827.doc 11 Changes Trainer: You documented the temp incorrectly. Change it to 102.4 and add a comment “MD notified” 1. Click VS Tab 2. Click 101.4 3. Click blue boxes 4. Type 102.4. Other fields can be modified from this window. 5. Click on ! (Significant Data). 6. Change to yes. 7. Click Save What Changed? Parenthesis around the value means data has been changed. Trainer: Time Limits on Making Changes 72 hours on admitted pts to correct mistakes 48 hours on discharged pts Information YOU enter Point out when hovering over a data field, click on hyperlink to display trended data. This cuts down on scrolling. Plan of Care 1. Click on the upside down triangle with double lines to add the Plan of Care tab to your view. Click Chart and ShowAll in left gray bar. 2. Pathway Pneumonia 3. Phase Admission. This is going to match the pathway to be added in EMR StarPanel. 5/7/2017D:\769836827.doc 12 Guided Discussion As Billy Bob’s nurse, what problems will you focus on during your shift? 1. Pulmonary-Gas exchange 2. Pain-Acute pain 3. Physical Regulation-Infection Do you expect the problems to IMPROVE, STABILIZE, or DECLINE? 1. Click Pulmonary on Left bar, middle way down 2. Click Start Priority Problem 3. Select Gas Exchange from dropdown a. Maybe related to – shortness of breath b. Expected outcome- Improve c. Start time now…type T in box for current time 4. A short term goal of “Maintain O2 Sats > 94% on supplemental O2”, at the beginning of the shift and at the end of the shift, you would document whether goal was met or not. 5. Click Save and Confirm Nursing Summary for Next Shift LCD Slide 3 Nursing Summary - Click on Plan of Care from left gray bar Brief synopsis of your shift before Shift change Include major clinical events & information For oncoming RN..does not replace face-to-face report Prints on OPC as reference for nurse during shift 5/7/2017D:\769836827.doc 13 6. Type brief shift summary: temp controlled with Tylenol. No further nausea, oxygen saturations improved on NC 7. Plan Priorities, type PCV in a.m. at 0500 8. Goal Status, met 9. Save and Confirm Exiting out of HED Click file exit to close HED Click file exit to close Care Organizer Guided Note Taking HED Nursing Documentation 1. The best way to edit a single item is to click on it. 2. To copy a column of information, click between the date and time. 3. Information that can NOT be copied: someone else’s charting, numbers, comments, older than 30 hrs 4. Capital letters in the gray bar tell the nurse to document every shift. 5. V/S will display in multiple tabs. List some: I&O, blood, quick assess for ICU. 6. It’s important to click “Show All” at least once a shift from the gray bar and when chart is open. 7. Documenting in a timely manner is important because providers view nursing data in StarPanel. 8. Plan of care includes documentation either at the beginning or end of shift. a. Beginning of shift tasks short term goal, changes to pathway, phase of pathway. b. End of shift tasks nursing summary, planned priorities, actual outcomes for goals. 5/7/2017D:\769836827.doc 14 Care Organizer, Admin Rx, IV Manage Trainer: We will go into the medication scanning portion of the class that includes: Care Organizer, Admin Rx, and IV Manage. First we will need to set up your preferences in the live region when you start your first rotation. Click File and Exit Click Exit and go to HED Production NR will set preferences in PRODUCTION and TRAIN. Preference Settings: 1. ROLE and SHIFT TIME (set to DAY/NIGHT shift) 2. Department… their first rotation (will rotate for 6 weeks before final placement) Set Preferences In Production and Train Trainer: You will use CO to create patient assignments & view meds schedules 1. Click View on top left hand side 2. Confirm that “Meds” & “IVs” checked 3. Click “Configure” 4. Click Default Care Relationship….Select Primary Nursing 5. Click radial button Exclude in middle of box 5/7/2017D:\769836827.doc 15 6. Scroll Available groups…select PHM. Hold CTR key down and select RES 7. Click ADD….OK Trainer: PHM and RES move to the R side, blocking ordered meds from displaying until checked by Pharmacy and schedules attached 1. Click Create Assignment button in upper tool bar. Pop-up box displays 2. Provider Type: click arrow- select RN 3. Care Relationship: Primary Nurse 4. Shift: Select the shift you work first. Click OK 5. Back time 15 min and up time 15 min. 6. Patient Dept: Unit you will work on – NR set to first rotation but must change each time they rotate to another location 7. File…Save Configuration 8. Click EXIT 9. Click “Create Assignment” again Trainer: Does everyone have their preferences saved? 10. Click Search box 11. Type your last name 12. click FIND Raise your hand if your name is NOT in the production data base 13. click Cancel 14. Click Exit out of assignment box DO NOT USE THE X TO CLOSE, USE EXIT Trainer: Will NOT create an assignment in the production region but will create an assignment in TRAIN. 15. Click Exit BOX… upper right corner 16. Click on the X to close out login box 5/7/2017D:\769836827.doc 16 17. Click HED TRAIN to open training region 18. Click view to confirm meds, IV checked 19. Repeat the configure, set preferences and create assignment in Train (use laminated sheets for patient name and department). 20. Click Refresh to see assigned patient in Care Organizer. Trainer: Locate the laminated sheets Physician Order sheet. On many units the nurses are transitioning from using the POS to electronically acknowledging orders online. In StarPanel portion we will point where this is done but Please work with your preceptor on how to acknowledge orders. Medications and your patient’s armband sheet 1. Locate the laminated POS. It contains detailed information about who ordered med, the order #, description and date 2. Make sure you are in Active view. Check overdues periodically. 3. Click on patient name. Click view and confirm/unconfirm 4. Expand Screen 5. Locate PCM number and compare with Wiz number on POS on left hand side 6. Compare items on Med History Screen (Med name, dose, route, frequency, start date/time, comments, status, and schedules) with order. Med schedules at the bottom of the screen 7. Clicks CONFIRM if order and schedule are correct 8. Click OK 5/7/2017D:\769836827.doc 17 Trainer: Famotidine displays to send message missing dose 1. Locate PCM number and compare with Wiz number on POS 2. Send a message to PHM for next med “Dose missing, please send”. Type unit’s phone number so PHM can call back if needed. 3. Click OK Trainer: Confirm the rest of the meds on your own. Make sure schedules are present and accurate 4. Click Famotidine and notice that the confirm button to the right now says Details. All information about the order can be found here 5. Click Cancel to close History Box a. What color displays in CO when order need confirming/verifying by RN? Yellow b. What do you check on to confirm orders? View – Confirm c. What button displays contents of the order including schedules? History d. What view should display when confirming orders? Active e. If a patient comes from surgery, CCL, or an unimplemented unit, will old orders (not new) display and should you confirm them? Yes, yes f. Why is it important to stagger meds back on the standardized schedule instead of sending Pharmacy a message to change the schedule when a pt meds get delayed? Drug Compatibilities and saves nursing time when meds can be given together. Also causes PHM delays in filling new meds if constantly changing schedules . Have one hr window to give med g. If PHM touches the med order in their system, whether anything is changed or not, will it come across to be confirmed again? Yes PRNs &Timelines 1. Click ACTIVE view 5/7/2017D:\769836827.doc 18 a. PRN meds display after scheduled meds. Click TO DO view. Locate Acetaminophen 325mg b. Under STATUS column, note last time given Trainer: H indicates IV hanging & moves along timeline. M indicates meds due 2. Click on the 5M due at 10AM-1200. Meds due display in the upper frame. RX-Scan MOM refused, Potassium late Trainer: Instruct learners to go to HED/ Admin-RX Scenario: Billy Bob was off the unit for his CT and now has 2 meds overdue . You take the meds to his room but he refuses the MOM. 1. Click Chart 2. Click Admin (no scanning of med is needed for MOM since he refused) 3. Select “Not given, patient family refused” from the dropdown 4. Scan Potassium: Note 2 warnings “Incorrect Amount” and “Admin Too Late” 5. Type 8 meq in dose field and Press ENTER. Incorrect Dose warning is gone 6. Scan Armband and ask for 2nd identifier 7. Override box comes up. Select “pt off unit” from the drop-down box. Click “ok” 8. Check Admin Review Screen and Administer med. Then Save and confirm. 5/7/2017D:\769836827.doc 19 a. Why did you learn about giving K+? Get warnings: “Too late” and “Incorrect amount” b. How did you fix the incorrect amount warning? Type in correct amount and press Enter c. How did you fix the too late warning? Forced to select a reason when scanning armband Famotidine, Isopto Drops Trainer: Give 2 meds…no issues Isopto Drops, Famotidine 1. Review Care Organizer (from lower tool bar). View 5 meds on timeline due at 1000. Insulin will be given next as a separate med 2. Click “Horizon Expert Documentation” from lower toolbar to jump back to Admin-RX 3. Scan Isopto drops from vertical barcode 4. Scan Famotidine (2 tabs, each barcode once). Press ENTER 5. Scan armband and ask for 2nd identifier 6. Administration Review Screen: make sure all meds scanned display 7. Give meds 8. Click CONFIRM Insulin SS & Scheduled Trainer: Meal times vary up to 2hrs to provide better fresher food for our pts. Nursing judgment should be used to determine if Insulin is given early or late. 5/7/2017D:\769836827.doc 20 Pharmacy adds two barcodes to insulin vials in the event the patient requires a scheduled and sliding scale dose. 1. Scan tadpole barcode Trainer: Note Matched Med Box displaying both SS and Scheduled Insulin. Blue display is the dose selected. Blood Glucose is 240. 1. Select Sliding Scale dose 2. Hover over blue area or click on underline name to view scale. Note 4 units ordered 3. Click OK 4. Tadpole always scans 2units; change to 4 units 5. Warning-Site Field Required: Pick site field from small drop down box next to the ! 6. Scan vial barcode 7. Select scheduled dose 5U 8. Click OK 9. Warning-Incorrect Amount: Dose displays 1unit. Type 5U. Press ENTER 10. Warning-Site Field Required: Pick same site field 11. Scan Armband. 12. Point out cosign box for real-time cosigning. Cosign Insulin Trainer: Note Co-Sign option if another nurse is in the room. Not commonly done. 5/7/2017D:\769836827.doc 21 Trainer: The norm is to find the patient via the census dropdown to document cosignature 13. COSIGN: Partner up… co-sign insulin by selecting partner’s pt from list of pts, then click documented insulin. 14. Click on the dose under co-sign select “click to co-sign” and Save. Trainer: Nursing judgment should be used to determine if Insulin is given early or late based on meal time. Note Co-Sign option by going to another patient, and click on Administered Insulin… Click Co-Sign. No prompt at end of shift to remind you to CS. Your responsibility Warnings MOM Scenario: Billy Bob changed his mind about the MOM. 1. Scan MOM, make sure you are back on your patient Trainer: Note Warning. 1. Scan MOM : Note warning- “ No current schedule Found – early for schedule…” What schedule are you getting ready to take/steal? 12noon (Afternoon class 1600) In this case, do you think it’s OK to take the 12noon (afternoon class 1600) schedule of MOM? No. Pay attention to the time the med is due. If it’s not a good idea to take the next dose, document as an extra dose. 2. Click third button on popup – “Extra Dose” 3. Click ok, change dose to 15 ml 5/7/2017D:\769836827.doc 22 4. Scan Armand. Click Ok for Override Reason 5. Save and Confirm Can you think of a legitimate reason for overriding a warning? Too Early: might be legitimate if pt leaving unit and want to give dose before procedure, etc. Too Late: pt returning from procedure Recently Given: Just FYI for nurse in case of duplicate administration but same med in various forms (IV and PO, PRN and Scheduled, or meds with Q2hr frequency) MED LABEL Potassium MEDICATION SCHEDULES FOR ADMIN-RX CLASSES 2012 DOSE 8 Meq ROUTE PO FREQUENC AM PM Y SCHEDULE SCHEDULE BID BL 0700 – Chloride oral sol TRAINING Late 1200 noon Famotidine 40 Mg PO TID cc 1000 1400 1700 On time MOM 15 ml PO Q4H 0800 1600 Pt refused 1200 noon 2000 1000 1400 Isopto Drops 1 drop Each eye TID 1700 Insulin Regular 5U Sub q TID cc 1000 1400 1800 Human At end Insulin Regular Sliding Human Scale D5 ½ NS + KCL 20 125 IV MEQ/L ML/hr infusion 5/7/2017D:\769836827.doc On time Sub q TID cc 1000 1400 1800 On time At end Now IV 23 Reset Scanner Link – Point Out 1. Trainer: Over 95% of scanning issues can be resolved when the scanner is reset. Synthroid is a complex barcode that can be hard to scan so using the reset scanner link will resolve most issues. Ask preceptor how to do this on unit. 2. Occasionally, resetting the scanner will not correct the problem; label is damaged or med is new in Vanderbilt’s system. For meds that won’t scan after the scanner is reset, place in red bin on top of the Acudose cart and document the issue. Pharmacy will pick up and take corrective action to fix. IV Manage Trainer: IV maintenance fluids, PCAs and epdiurals are not scanned into Admin – Rx but are scanned into IV Manage 1. Go to Care Organizer 2. Click on patient’s name from the bottom of the screen so only your patient displays at the top of the screen. 3. Look in Group column to note meds charted in IV manage (Maintenance fluids, TPN/L, fluid boluses, Med drips PCA syringes, Epidural bags). 4. Scan Armband on laminated sheet 5. Click IV Manage 6. Scan barcode of new bag of D5 ½ NS w 20KCL 7. Dosing Wt = 0 8. Infusion Rate = 1 started 9. Click SAVE. Note color change 10. End other bottle – checkmark end bottle and save 5/7/2017D:\769836827.doc 24 11. Click Exit and refresh Trainer: Mention in Vitals I&O a zero placer will display when a new bag is ended or Dc’d. What are the steps involved with bar code scanning of meds? Scan Med, Scan armband and ask for 2nd ID, Give med, Confirm If med will not scan, what should be done first? Reset Scanner Can the scanner be reset from the CWS? Scanner Reset from HED Most times meds will not be given at the exact time they are due. What’s Vanderbilt’s standard for administering? 1 hour before and 1 hour after due Guided Note Taking Break 10 Min …Lock Screen …Click LOCK left lower tool bar 5/7/2017D:\769836827.doc 25 LCD Slide 4 OBJECTIVES: HEO and StarPanel Explore StarPanel.. EMR ◦ Look up test results and documents ◦ Complete Admission History form ◦ Assign a Pathway (Plan of Care) Enter orders in HEO/Wiz… CPOE ◦ Enter Nursing Orders for New Admission StarPanel Inpatient Whiteboard TRAINER: Click on StarBrowser displays in lower tool bar ... this is StarPanel Patient List: Census view Black bar: Many options including MR # or name search Go TO Icons: left of the black bar Print Desktop Signoff the workstation Wiz Production HED Production …others Teletracking Veritas Locate RED CARD on monitor. This is your patient. Navigating: 5/7/2017D:\769836827.doc 26 a. Single click to open documents b. Frames: Adjust by double clicking in any white spot or dragging frame with double arrow c. Yellow tabs: specific to the opened patient i.e., patient note d. White tabs: Generic, i.e., groups of patients e. Click “Pt List” to return to this view of pt’s 1. Click Blue ACTIONS text next to your patient’s name 2. Click My Actions – Change 3. Select Inpatient Nurses from yellow box 4. Click FAST LABS (24 HR Labs will not display data) Drag frame up. Displays in Reverse chronological order with Abnormal values display in red a. Hover over lab to display entire name and reference ranges b. Click on PCV to see TRENDS 5/7/2017D:\769836827.doc 27 c. Click GRAPH d. Close by clicking in Trends box and X out of Graph 6. MAR: Click ACTIONS, MAR… ALL DAYS Meds display from Admin-Rx and VPIMS, the OR system Open boxes mean “not given” or “given by another nurse” Closed “given” Yellow “comments” note K, and blood glucose graph help track why med not given Click Levofloxacin 750 mg q24 Red Line indicates there was a Downtime and see paper MAR Drug Reference: Hold CTRL and click on drug name in Blue Trainer: Point out ED and OR documents can be accessed via the ACTIONS menu 7. Click ALL DOCS from ACTIONS menu: notes, communication, reports Type in search field “Progress” and to view all progress notes Open a progress note & view in frame below 7. Click OPC from column Overview of Patient Care Used to give and receive report… Handover tool Pulls in information from orders, test results, nursing & MD documentation Trainer: Point out the following as learners locate Situation: SBAR format Team Text Page can be done from here Blue text is a link to the document 5/7/2017D:\769836827.doc 28 Admit History can see Contact info and present on Admission info Clinical Alerts: Code, Allergies, Isolation, Fall, Braden, Adv. Directives, No Information pt Background: past medical/surgical history Assessment: Plan of Care includes Pathway, Nursing Summary and Plan Priorities, and goals Assessments that have NOT met standards for a specific system/pain Progress Notes/Consults/Rad/Rehab: replaced with new notes if documented. 24hr labs Weight, V/S, I&O, pain Invasive line and vents info Recommendations: 3. Current, Active orders from HEO Wiz DEBRIEF: Can you see the overall benefit of using this tool? Admission History Scenario: 57 year old Billy Bob is admitted to your unit after being seen in the ED with fever and cough. CXR revealed lower lobe pneumonia bilaterally. When a new patient is admitted, how many hours to complete an Admission History? complete within 24h 5/7/2017D:\769836827.doc 29 LCD Slide 5 Trainer: Admission History form is divided into 3 sections with specified times to collect information. Section I: 1-2 hrs with critical information for safe patient care Section II: 6-8 hrs for planning care Section III: Collect 20-24 hrs for discharge plans and functional screens What’s the quickest way to access an Admit History form on a patient? ACTIONS 1. Click Adult Admission History from ACTIONS menu. Trainer: Follow along to complete the form. Some data from previous admission might be pre-populated. Always confirm pre-populated data i accurate. Section I a. Height: 5 ft 11 – stated and data collected today- use calendar to select b. Weight: 189 lbs stated.. Peds 16kg measured c. Admitted today @ 0850 d. From ED e. No religious, cultural or ethical practices to consider. Confirm any prepopulated data is accurate f. Patient has NOT been exposed to TB g. Reason for admission: Cough h. How Long: 1 week 5/7/2017D:\769836827.doc 30 i. How does patient care for problem: Robitussin Legal Documents j. Advanced directives/ Living will scanned in chart k. Family to bring in Durable Power of Attorney document Communications l. Historian Family Member: m. Sally is patient’s sister and support person who is staying with patient n. Her phone 333-3333 o. Relationship: Sibling p. First Person: Same as designated support person q. Second Person: Information can be shared with John r. Instructions, Care For After Discharge, Transportation: same as designated support person Trainer: There is a link to gather the Home Meds List (PAML). This will be demoed in HEO/Wiz. s. Allergies: Verify with patient that all allergies are correct. Remove one allergy by clicking on the Red X. t. Add allergy for Morphone by clicking New. Enter reactions, severity. u. Save Present on Admission q. CPAP: used at home but the patient did not bring it r. Alcohol Screen: Denied intake… 5/7/2017D:\769836827.doc 31 v. If you are unable to complete section I then save as draft Section II Patient Summary: Receives all updated information from inpt and outpt visits. Most accurate patient information source. Click to expand or collapse. Tobacco Screen: Denies use Immunization Screen 1. Open Immunization Record: Click Blue link a. Barcode scan of immunization med will electronically update record b. Manual entry can be done if patient states given at earlier date 2. Stop Screening: a. If ICU, STAT name with incorrect birthday or patient unable to provide history b. Complete immunization screen when correct data is obtained c. Stop Screen if pt <6 months old 3. Flu immunizations Screening – will see this in Fall. 5/7/2017D:\769836827.doc 32 LCD Side #6 TRAINER: Nursing Protocol order electronically enteredd into HEO/Wiz 10 a.m. administration time scheduled for next day Better for our patients and Medicare/Medicaid requirement Pediatrics: Pharmacy will give all the flu immunizations, not pt’s nurse 4. Pneumovax: Same type of screen as flu… do NOT complete 5. Scroll through Religions, Pain, Nutrition, Social Work, & Learning Readiness to end of section II. do NOT complete 6. Verify Pre-pop data 7. Save as DRAFT Amend Admit History Trainer save your form as FINAL and demo how to add amendment 5/7/2017D:\769836827.doc 33 Is it OK to complete all sections at the same time? Yes If all sections are not complete, what should you do? Save as Draft What if someone changed the data you entered? tracked electronically What’s the timeframe for completing section I? 2 hours of admission Assign Pathway Trainer: a Plan of Care should be assigned to each patients medical record. Vanderbilt’s POC are called Pathways. 1. Click ACTIONS 2. Click E-Docs Pathway 3. Search for Pneumonia 4. Select 5. Click on ACTIONs menu next to patient’s name. 5/7/2017D:\769836827.doc 34 6. Click AllDocuments to view E-Docs Pathway Pathway is in AllDocuments and can be accessed easily by team. Also available as a hyperlink in Assessment section of OPC. Guided Note Taking 1. Clicking on ACTIONS opens a menu for quick access to patient information & documentation. 2. OPC is an acronym for Overview of Patient Care & contains most recent documentation/tests. 3. The Admission History form is divided into 3 sections. a. Section I: Critical information needed to deliver safe care, i.e., Allergies. Complete in 2 hrs of admission b. Section II: Positive screenings for Flu and Pneumovax generate Nursing Protocol order in HEO/Wiz with a schedule time of tomorrow 1000. In Peds, Pharmacy administers . Complete within 6 to 8 hours. c. Section III. Functional screens for PT/OT/Speech/CM should be completed within 24 hrs of admission and on short stay areas at least 8 hrs before discharge. 4. Existing data imported into the Admit History data base should always be Verified. 5. Meds documented in Admin-RX display in StarPanel in the Actions menu by clicking on MAR. 6. The Plan of Care (Pathway) is accessed from StarPanel by clicking on ACTIONS button & selecting eDocs Pathway 5/7/2017D:\769836827.doc 35 HEO/Wiz 1. Click Desktop Icon 2. Click Green Wizard (Wiz Train) Trainer: Census derived from Medipac, application for Admit, Transfer and Discharge Computers in this training rooms are set to display the census of _____unit Symbols LCD Slide 7 HEO/Wiz Census Legend Security Indicators N: No information S: No information…Usually police involved G: Can give general information out according to policy Search A. Under Stations, click the unit you will work on. Note census change. B. Type (ZTEST) in search box and press ENTER. Displays pt’s from all units. C. Click Refresh button… don’t forget to refresh if pt not found on census. D. Click back on training census. Paper Documents Still a few Computerized Physician Orders pages 1 and 2 Generally print to Medical Receptionist’s printer when orders entered in HEO/WIZ Patient information and MD who authorized order at top Each order has a number 5/7/2017D:\769836827.doc 36 STAT orders display bold … see page 2 Start & stop times (right side of page) Open-ended orders (continuous) display start time. Remain until deleted or pt discharged – see #10 NHO One-time orders - see #13 culture urine bacteria Timed orders – See #14 (pg 2) Percocet. 72 hrs stops Far right column provides a place for MRs to note when dept called, etc MR & RN initials at the bottom when orders are processed and verified Computerized POS is not a permanent chart document Requisitions: Lab pg 3 ► Reqs print on unit if procedure if test done on unit i.e. RT and EKG ► Other Reqs print in performing department, i.e. Radiology, Nutrition Svc. ► Lab Reqs are bar coded: 2 barcode above double line are patient information Barcodes below line defines tests Lab scans Req when specimen is received ► Multiple tests print on same Req if tests can be run in same dept (CBC and PCV) ► Full signature, VUNet ID, dates & time from person collecting specimen. ► Text in center section gives directions on how to collect specimen, color of tube ► If test ordered STAT, MR calls the performing department, except for Labs. ► Batch Reqs print after midnight if the test is to be done after MN, ie, next day’s labs TRAINER: Demo how to reprint reqs 1. Double click on patient’s name 2. Click on Reprint Requisitions 3. Select your test 4. Click Reprint Checked Requisitions. (Note: If it is red with an accession number, it cannot be reused) 5/7/2017D:\769836827.doc 37 Nursing Protocol Orders New Admission Scenario: Billy Bob arrives on your unit, now that a bed is available, after spending 8 hours as an admitted patient in the ED. The nurse in the ED completed the Admission History. It’s time for you to enter some orders in HEO/Wiz. 1. Double click name on red card or slips of paper on monitors on laptops 2. Select Enter Orders 3. What order type? Protocol (Nurse to nurse order will pass along information and doesn’t require Co-Signature from MD) 4. Physician? TEST 5. Press Enter & Select Dr. Test from right upper window Trainer: Screen is divided into left and right windows Top Left window: Name, rm. # MR #, Sex & UserID. Verify correct pt Inside left window: Orders with numbers Organized by categories Always review active orders before entering new ones Right Window - Upper window displays common orders for that unit Center window - colored text asks questions or gives instructions Bottom window - Flashing cursor. Type here. Toolbar @ Bottom of Screen: OOPS and DONE Trainer: Instruct learners to NOT enter beds or pressure ulcers. Can demo on the screen but do NOT accept. Lots of cleanup involved. BRADEN: 6. Type Braden: (Braden Q for Peds) Pressure Ulcer Management- Braden Scale (Skin risk). Be creative. Skin Assessment is done in HED. 7. Demo adding a pressure ulcer a. Click Add a Pressure Ulcer b. Location: Buttocks c. Side: Left, medial, superior 5/7/2017D:\769836827.doc 38 d. Click Select Stage: 1. e. Pressure Redistribution Item: Chair Cushion f. Click Save g. Click Done SYMBOLS: Left Window Sun: new order Paragraph sign: order will drop off in 24 hrs… one time order Note order # assigned after order accepted 7. PAML- Pre-Admission Medication List (Home Medications) Includes: prescriptions, over the counter, herbal or vitamin supplements Complete within 2 hours of admission Providers reconcile PAML during patient’s admission and time of discharge Across top in gray area: patient’s information Top left is the Medication Search box Box underneath is the Patient Summary. This is the patient’s current home med list from clinic. Ask the patient if she/he is still taking the medications. If yes, click on the yellow arrow to move med to right side of 5/7/2017D:\769836827.doc 39 the screen under Pre-admit List. This box is where all home meds are updated. 8. Click DONE…Accept Trainer: Review orders. If Corrections? Return to order entry. Exit w/o accepting if wrong patient. Orders are correct. Click ACCEPT More Orders Trainer: Billy Bob complains of pain and you page Dr. Test from the OPC pager link. (Starbrower open on lower tool bar) While on the phone, Dr. Tests gives you several verbal orders to enter. 1. Double click name on red card 2. Select Enter Orders Trainer: What order type? Telephone 3. Type TEST, press Enter. Select Dr. Test from right upper window Discontinue a. Click Guaiac from left window b. Discontinue c. Reason (Dr. cancelled) Modify: to 75ML: D5 1/2 NS with 20 KCL @ 125 ml/h a. Click current IV order in left window b. Select Modify. Trainer: Notice order in Upper R window. Identify parts: Name, Frequency, Priority, Duration, Comments c. Click Rate to modify SYMBOL: Symbol for modify? Square New: PCV in AM 0500 – “don’t draw L arm” a. Type PCV in the right bottom corner. Select from List 5/7/2017D:\769836827.doc 40 b. Select PCV blood –LAB c. How Often: in AM- 0500 d. When to Start? Routine e. Comments: Don’t draw from left arm f. What Symbol displays before the new order? Sun Switch: Change diet to Regular a. Click on NPO left window b. Click Regular. Trainer: Treated as new order c. No Comments: Press Enter Medication Order: Morphine 30 mg PO q4h PRN a. Type Morphine b. Select # 2: Morphine Immediate release tab c. Dose: 30mg d. Route: PO e. How Often: q4h PRN f. When to Start: Routine…in green g. How Long: 3 days or click ENTER h. Comments: for abdominal pain > 4 (required) NHO if nauseated Blood: Dr. Test ordered 2 U of blood to be transfused because your patient has a PCV of 21. This is not an urgent request and as a nurse you determine when it’s best to give to the patient, i.e, after a test, or bath. Type and Screen req will print if no results in StarPanel within the last 72 hrs when transfuse order is entered. 1. Click on Transfuse Order in left window 2. Click Request Blood Product from Blood Bank 3. Review information – confirm accurate 4. Request 1 unit 5. Click SEND, DONE, ACCEPT 5/7/2017D:\769836827.doc 41 LCD Slide 8 Processing of Orders by Medical Receptionist Orders & Reqs print to Medical Receptionist (MR) and placed in unit appropriate area MR: Notifies RN of STAT Orders and Labs MR: Notifies Department of Other Tests RN: Acknowledges Orders online Emergency Departments: Orders do NOT print. Lab Requisitions generate to printer closest to pt’s room LCD Slide 9 Steps to Acknowledge Orders Electronically TRAINER: Review slide steps Guided Note Taking 1. To ENTER a new order without using an order set, just type it in. 2. To MODIFY or DELETE an order, just click on order in left window. 3. Identify the two places where Allergies alerts can be entered. Nursing Admission History Form and HEO/Wiz. 4. Skin is assessed in HED and Braden Skin Risk is documented in HEO/Wiz. 5. When taking a verbal order from an MD, always verify who will Enter the order. 6. When requesting a unit of blood, click on order in left window and Request blood product. 7. PAML is an acronym for Pre-admit med list (home meds). Nurses review home med list with patients when they arrive on the unit and as needed. TRAINER: If time permits, have students complete Seek and Find 5/7/2017D:\769836827.doc 42 Trainer Responsibilities after class is over Update Amanita 1. Check sign-in roster where you noted that they said they passed boards 2. go to this web site: http://health.state.tn.us/Licensure/default.aspx confirm they have passed boards 3. If passed, take training flag OFF 4. For those who have NOT passed boards a. Change Role to Medical Receptionist – Other 5. place in comments “Nurse Resident Training completed m/d/y Discontinue all orders after each class-MD training ID TRAIAKO… 5/7/2017D:\769836827.doc 43