New Employee Orientation Patient Hand Offs
Reviewing the Patient Chart for Hand Offs Hand-offs require a review of the patient chart Hand-offs should be done with each patient assignment change Review the PAL, Orders, MAR and Tasks Correct deficiencies in the patient charting before handing off the patient Review the paper chart and the electronic chart Enter the electronic chart check order
Sections on the PAL Patient Name Demographic Section Notification Section Tasks Results The patient from the list will display on the PAL. The PAL contains 5 columns with defaulted data in each column. The first column (blue) is the patient name. The second column (yellow) contains location, allergy status, age, sex, service, attending, and an IV icon if the patient has an IV. The third column (green) contains lab notifications, radiology notifications, order notifications, and sticky notes. The fourth column (pink) contains nursing and medication tasks which are Overdue, PRN/continuous, Current. The fifth column (purple) contains the dosing weight and the actual weight along with any user defined specific result. The PAL only displays information from the timeframe identified in the blue bar. The off-going nurse should have her/his time period displayed and the on-coming nurse should have her/his time period displayed. The two timeframes will overlap and show all the potential nurse reviews and notifications.
Icons in the Demographic Section Make sure the allergy information is up to date. Loc-Patient Room Number Allergy- Dark Blue Circle indicates patient with a documented allergy Clear Circle indicates patent with no known allergy Clear Circle with red! indicates allergy status not addressed IV-icon displays for a patient with a continuous IV medication order
Icons in the Notifications Section Make sure the orders have all been reviewed and you are aware of the other notifications. If you need review on how to perform nurse review, refer to module PAL PT list. The Notification Section shows changes in patient results and orders which have not been acknowledged electronically by the user for the PAL timeframe. **NOTE: Only instances which occurred during the timeframe displayed in the PAL information bar will display. A clipboard in the Lab or Rad column denotes a new result. The red! and check indicates a critical value within the results. A clipboard in the orders column signifies new orders which have been previously reviewed by a nurse or do not require review. Eyeglasses signifies that new physician orders which have not been electronically reviewed by a nurse. A red! in a clipboard in the orders column denotes Emergent or Urgent Pharmacy orders. Sticky notes in the Notes column are useful to communicate information that is relevant but should not be part of the medical record. Sticky notes carry from shift to shift and encounter to encounter.
Icons in the Task Section Icons Red Hearts all nursing care tasks not covered by another icon Yellow Clock forms which are pending validation (require co-signature**) Capsule and syringe medication task to be done IV bag IV fluids are ordered on the patient Blood Drop lab specimen to be collected Person behind a Chair activity task is due Blue Lungs respiratory task is due Evaluate the overdue tasks to find out why they have not been completed. Make sure all tasks requiring co-signature have been addressed. **Note: Admission databases and assessment forms completed by LPNs and SPCTs must be co-signed by a RN. All forms completed by graduate nurses with the exception of basic care forms, vital sign forms, and glucose monitoring records must be co-signed by an RN. Any automatic referrals generated from admission databases will not be forwarded until the form is authorized.
Handoffs Using the Task List Scheduled Tasks Review all tabs of the task lists for Overdue and Pending Validation tasks. Look through all tasks to assess patient workload needs.
MAR Tab Overdue Medication Task Look at all overdue medications. The alarm clock at the front of the timeframe line denotes overdue tasks. To view all the overdue tasks, click on the alarm clock and scroll back using the scroll bar at the bottom of the screen.
Mar Summary Scheduled, PRN, Once, and Continuous IVFs display on the MAR Summary. The MAR Summary can be used to see larger blocks of the medication information during the hand off.
Patient Care Summary The Patient Care Summary contains information similar to what was documented on the paper Kardex. The information on this tab flows from documentation in other parts of the electronic medical record. This tab gives a quick overview of the patient. It does not contain all the chart information.
Orders Tab Change orders display All of the patient orders are viewable from this tab. Which orders display (active only, active and discontinued, medication only, etc.) are determined by which filters the user chooses. Filters and views for orders are changed using the Display dropdown, the ellipse box, or the Customize View option.
Performing Electronic Chart Checks The view and filter options must be set properly in order to verify all order changes to the patient chart (new, modified, canceled, and discontinued). When not performing a chart check, views and filters can be set to the Nurse s preference. 1. Open the Orders tab 2. Click Customize View to open the Customize View window
3. In the customize view window, choose a. Last Updated (position above Details ) b. Group orders by and choose None d. Sort orders by Last Updated When properly set the view displays as below. When completed, click OK. Last updated displays above Details
4. On the orders display, set All Orders (All Statuses) This will display electronic orders with the newest orders at the top of the screen and the oldest orders at the bottom of the screen. 5. Search for the last Chart Check Performed 6. Review all orders starting at the last chart check and ending at the current time.
To document that the chart check is complete 7. Click Add order 8. Enter chart in the Find box to locate the Chart Check Performed order. Click on the order name to choose the order, then select Done.
9. Enter the Period Start and Period End. If another nurse was assisting with the review, a name can be entered in the Second Nurse Performing Chart Check line. 10. Click Sign at the bottom of the page. Enter your password in the authorizing signature box. Click OK, then refresh the screen. The Chart Check Performed order will display at the top of the orders section with a status of Complete.