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)
LCD Slide 1
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”?
· 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
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.
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.
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 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
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…
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
LCD Slide 2 Assessment Principles
· 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
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 Standard Met
· Skin: Review section only
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
· 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
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.
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
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
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.
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.
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.
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
LCD Slide 3
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
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
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
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