Nursing Notes Best Practices. Anna Rivera, Senior Application Specialist Vanessa Sampedro, Application Specialist

Transcription

1 Anna Rivera, Senior Application Specialist Vanessa Sampedro, Application Specialist

2 Topics Configurations Templates Template Sets Questionnaires ROS Coding (ASC Codes) Interview Forms Scheduler: Areas & Appointment Status Output Manager User Lists & Answer Sets Nursing Notes Work Flow Anesthesia Note Pre-Procedure Intra-Procedure Post-Procedure Follow Up Call

3 Configurations Templates Anesthesia Note Pre-Procedure Nursing Note Intra-Procedure Nursing Note Post-Procedure Nursing Notes Related Templates Template Sets Questionnaires ASC Pre-Anesthesia Pre-Anesthesia Evaluation Pre-Incision/Scope Introduction Patient Authorization Follow-Up Contact ROS Coding (ASC Codes) Interview Forms Scheduler: Areas Scheduler: Appointment Status Output Manager User Lists & Answer Sets

4 Configurations Templates Remove the unnecessary Remove from the templates sections that will never be used.

5 Configurations Templates Change the order of the sections Organize the sections in the same order that the Nurse will document the case. Just click and drag the section header to the appropriate location in the template.

6 Configurations Templates Customize your template Click the header to expand and view the section properties and signing rules. Rename the sections to follow your current verbiage Make fields required before signing or just create an alert to user if left blank.

7 Configurations Templates Share sections across templates Display the same section across different templates. This eliminates duplicate documentation and the user having to toggle between 2 templates to view information captured by a different staff member.

8 Configurations Templates ASC Quality Form Display the Safe Surgery questionnaire sections on the corresponding Nursing Note. The nurse can document the answers from their note and these will populate the ASC.

9 Configurations Templates ASC Quality Codes Display the ASC Quality Code on the Post Procedure Nursing Note

10 Configurations Templates Discharge Arrangements Add the Discharge Arrangements from the Pre NN to the top of the Post NN Note. Post Nurse can easily see the Driver name and relationship.

11 Configurations Template Sets Organize the order of the templates, so that the Nursing Notes appear at the top in the order they are accessed.

12 Configurations Questionnaires You can configure questionnaires which may then be placed into the templates. While there are several types of questionnaire sections provided, consolidate most of your questions into just a few sections.

13 Configurations Required Questionnaires Make all the questions required to ensure each question is addressed. You can have N/A as an option for questions that don t apply.

14 Configurations Patient Interview Form (PIF) The biggest bottle neck is in Pre-Op because entering conditions and medications can be time consuming. To avoid this, configure a location specific Patient Interview Form (PIF) for the Endoscopy Center. Create a shorter PIF with the most common answers as default bubbles, and also add the items that you ask every patient, this can make the patient check in flow quicker and smoother.

15 Configurations ROS Configure a ROS to use in place of the Nursing Assessment questionnaire and include only the symptoms reviewed during the pre-nursing assessment The ROS appears on the PIF, facilitating the documentation process.

16 Configurations Coding Default ASC Codes G Codes G8907 and G8918 are documented on most procedures and enabling this feature will automatically add these codes. The codes may be manually updated during the procedure on the ASC Quality Form or Post Procedure Nursing Note if there is an incident.

17 Configurations Status and Areas Areas can be configured and associated to a Status. This facilitates on the scheduler identifying where the patient is from arrival to discharge Configure your areas first then associate to the status

18 Configuring User List Allergies Spending time on the configurations will save lots of time when documenting. Eliminate the clicks. For allergies, check off Display as alert the most common responses

19 Configurations User List IV Setup Configure the list with the most common Sites and Types defaulted

20 Configurations User List Administered Medications Configure the list with the most common medications and dosages Disable the popup

21 Configurations User List Prep Configure the list with the most common preps and results

22 Ribbon/Answer Sets Configuration You can create multiple answer sets for different scenarios and even set the most common answer set as the default for the questionnaire.

23 Follow Up Call Nursing Note Most practices make 3 attempts to call the patient, then send a letter on the 3 rd failed attempt. Configure your answer sets to follow the workflow

24 Once configurations are completed The nurses workflow will be smoother

25 Tips for documenting the Nurses Notes Physician Standing Orders Anesthesia Note Pre-Procedure Nursing Note Patient Interview Form (PIF) Intra-Procedure Nursing Note Post-Procedure Nursing Note Follow Up Call Nursing Note

26 Prep the chart before the patient comes to the back Once the patient shows checked in on the scheduler, enter the information not required from patient. Add the Nurse & Staff Document the Physician Standing Orders for all notes Add the Instrument #

27 Anesthesia Note Incorporating the Anesthesia note eliminates duplicate documentation. Ex. The patient s medical history can crossover from the Pre Nurses Note. The ASA Class can crossover to the Procedure Note. If you are not using the Vitals Monitor module, enter one vital for each Nurses note as a baseline, and scan in the rest of the vitals.

28 Pre-Procedure Nursing Note Patient Interview Form (PIF) Reduce the check in bottle neck, by using the PIF to capture the patient s medical history.

29 Pre-Procedure Nursing Note Review of Systems (ROS) The ROS on the PIF, facilitates documenting the nurses assessment

30 Pre-Procedure Nursing Note Questionnaires Default answers and use answer sets

31 Intra Procedure Nursing Notes Document the time markers and specimens real time. Time Markers and Specimens can be documented from the video capture screen without interrupting the live feed.

32 Intra Procedure Nursing Notes Vitals In the absence of the Vitals Monitor module, enter only the first set of vitals and scan in the rest.

33 Follow Up Call Nursing Notes Use the answer sets to document the attempts

34 Status on scheduler By updating the scheduler status with the follow up call status, it is easy to see at a glance which patients still need to be contacted. Follow up call complete, could be the final status

35 Template configurations Make fields required Remove sections on the notes that will not be utilized Arrange the sections to follow the Nurses workflow Organize the thumbnail documents so that the Nurses Notes are at the top Configure the user lists Avoid folders when possible Questionnaires Consolidate the questions into 1 or 2 sections Create and default answer sets, when possible Patient Interview Form & ROS Quickly capture the medical history through the PIF Utilize the ROS on the PIF to facilitate the nurses assessment

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