2017 RN Refresher Workflow Best Practices Captions

Transcription

1 Slide Agenda Caption 1 Hello and welcome! This is Kelli Magoon with the EMHS Clinical Informatics team. I'd like to thank you for checking out this ecourse. It is the first of three "RN Refresher" modules being released in March, We know you spend a lot of time in the patient's electronic record. Do you think you spend too much time? When we round with staff, we hear your concerns. We know that patient care tasks are piling up. We know how hard it can be to track down information in the chart, when you "have" to click a dozen menu links. We understand that it may be perplexing if you are asked to "fix" a patient's allergies, when you documented them the same way you always have. We know you are able to complete your documentation AND we suspect that there are tools available to you that might make it easier for you that you may not know about. That's what these ecourses are for......to simultaneously help you to REDUCE the amount of time you spend in the record, REDUCE the chance you will have to "fix" documentation or clear a boat-load of old tasks, and improve your overall satisfaction. A printable transcript of each course is available by clicking the paperclip in the lower right corner of the screen at any point during the presentation. Also, we've included a link to the Clinical Informatics Class Evaluation form and we would love to hear from you. You may or may not include your name, but please do let us know how we're doing. Now, in this ecourse, we are going to spend about 13 minutes talking about how to make Care Compass work for you. Are you someone who hasn't yet embraced Care Compass? Please give me a chance to show you how Care Compass can improve your documentation experience. Page 1 of 6

2 Start from Care Compass 4 You should always start documentation from Care Compass. This is because the system provides you with prompts for required documentation. Looking at our patient on-screen, we can already see that we need to document Allergies. We can also see that the patient does not yet have an admission order. How can we tell that? Check out the Plan of Care column. All admission orders reside within special Admission PowerPlans. When PowerPlan orders have been placed, they will appear in the Plan of Care column on Care Compass. You may ask, "Why is this important to me?" Well, many PowerPlans contain orders that fire to the Activities column. For example: If a provider orders Neuro Checks, tasks will appear in the Activities column that will open to the documentation tools in the Patient Chart View. When you are beginning to chart on a patient, you'll want to keep this in mind. 5 The number in the Activities column indicates how many activities are currently due for the patient. 6 Please click the number to begin charting. 7 The Activities panel opens. When patients are admitted, there are several tasks that fire automatically. These will vary depending on the patient's age, encounter type, and location. Done/Not Done Tasks 9 A good way to begin admission-related documentation is to document the patient's preferred pharmacy. 11 Since we've successfully documented the patient's preferred pharmacy, it's time to chart the task as done. Since it's already highlighted, all we need to do is click Done in the lower right corner of the Activities panel. Go ahead and do so. Page 2 of 6

3 PowerForm Tasks 14 This patient's preferred pharmacy has been documented and that task has been completed, leaving the Admission History and Basic Admission Info tasks. All patient care tasks that appear on Care Compass will be seen by nurses and nursing support staff. However, some tasks must be completed by nurses. For instance, the Admission History PowerForms must be completed by nurses, while the Basic Admission Info PowerForms can be delegated to nursing support personnel. When a nurse is admitting a patient without the immediate assistance of a tech, he/she will want to start with the Basic Admission Info PowerForm. This is because, before orders can be entered by the patient's physician, APN, or PA, the Height, Weight, and Allergies must be documented for the patient. The Basic Admission Info Forms contain fields for height and weight documentation. Therefore, starting with one of these ensures this critical information is available when orders are being placed. Let's start by completing the Basic Admission Info Form. 15 Click to highlight the Basic Admission Info Adult task. 16 Click the Document button in the bottom right corner of the screen. 18 The Basic Admission Info PowerForm task is removed automatically! Next, click to highlight the Admission History task. 19 And then click Document. 21 Provided all required (yellow) fields within the PowerForm were completed, the Admission History PowerForm task will be gone upon your return to Care Compass. Tasks corresponding to any vaccines ordered as a result of your vaccination screening will appear. Always remember to refresh Care Compass to ensure that all fields are up-to-date with the most recently charted data. Page 3 of 6

4 Identifying & Completing Partially Completed Form Tasks 25 In order for PowerForm tasks to be completed, all required fields must be addressed. There are times when forms are signed before they are finished. Examples of this include: When the staff member needs to address something else urgently and must sign the form before completing it; When the staff member forgets to complete a required (yellow) field in the PowerForm; When the required clinical data is not present at the time the form is signed. Any tasks associated with the form will remain on Care Compass until the required information is added. 27 This patient has a task to complete the Admission History PowerForm. Let's take a look When I open this form, I can tell immediately that it has already been started. Look at the sections listed in the navigator. If a form has ANY sections in bold, then someone has previously started the form. Notice that the Social History section has a red asterisk beside it. This indicates that required information is missing. 29 As you can see, the CAGE Assessment question has not been answered. You may proceed with completing the documentation now. 30 Once you have determined that the PowerForm is complete, click the green checkmark to sign it into the permanent record. 31 There is one task showing for our patient. 32 It's still that Admission History PowerForm task. Let's click the Minutes Ago button to refresh the screen. 33 The task now goes away. Modifying PowerForms 36 Signed PowerForms are housed on the Form Browser link. PowerForms may also be edited from here. I'm going to demonstrate using the Admission History PowerForm, but keep in mind that you may modify a PowerForm with an associated task from Care Compass as shown in the last segment. Page 4 of 6

5 36 All PowerForms, with or without tasks, may be modified from the Form Browser Link. 37 The Admission History PowerForm is showing with a red icon. This indicates that it is missing required data. Right-click the form And select Modify. 39 Go to the section missing data. 40 We can see that the Alcohol assessment was completed. The patient does not drink, and therefore, the CAGE assessment was not performed. 42 The icon beside the form has changed to blue, indicating that all required fields have been completed. Let's return to Care Compass to see what's changed there. 48 Here we are in Care Compass. I can tell by looking at the screen that the physician has entered the admission orders. How can I tell? Activity View Check out the Plan of Care column. See how there are two items listed there? These are PowerPlans entered for the patient. All Admission Orders are included in special PowerPlans. Ordered PowerPlans appear in the Plan of Care column on Care Compass. This patient has two ordered. The first is the Ortho Trauma Admission/Transfer PowerPlan. This is the one containing the Admission orders. The second is the Readmission Prevention PowerPlan. This is used at EMMC only, presently. We can also see that there is an item in the Activity column. Let's take a look. 49 The patient needs to have CSM Checks done. Let's go ahead and get started with that Rather than launching a PowerPlan, this task launches what is called, "Activity View," in the Interactive View and I&O link of the patient's chart. Activity View pulls together the various items (or lines) needed to document a particular assessment or task from throughout the various Interactive View and I&O bands. Page 5 of 6

6 51 Once signed, the data entered here will be distributed to those places in the bands. Columns in Activity View display in intervals corresponding to the ordered frequency of the assessment. The leftmost time column will display with the current (or NOW) time. A nice thing about Activity View is that the Now column will automatically open for documentation. Notice the checkbox at the top of the column. This checkbox indicates that the column is open for documentation. This allows you to jump right in and enter the patient data. If you would like to document in Activity View at an alternate time, simply right-click the time at the top of one of the other columns and select, "Insert Date/Time." Proceed as usual. 54 The purple font changes to black when signed, indicating that the results have been saved to the record. Next, let's return to Care Compass to see what's changed there. 55 The CSM task still shows in the Activity column. We need to refresh the screen. To do so, I will click the Minutes Ago button in the upper right corner of the window. 56 Let's open the Activities window again Great! The 15:00 CSM Check task has been removed, as expected. The task for the next hourly check is all that remains in the 2 hour view. 59 Hopefully, you can see the benefit of starting your charting from Care Compass and... If you haven't been doing so, now is the time to start. When used correctly, there are no overdue and seemingly "redundant" tasks to wade through......and Care Compass becomes the meaningful hub of activity it's meant to be. Okay, next up is an ecourse focusing on ways to improve your efficiency within the patient chart. Be sure to check it out! I'll see you there. Page 6 of 6