Vanderbilt Psychiatric Hospital Electronic Medical Record: Unit Resource Manual 01/15/10 Vanderbilt Medical Center Systems Support Services.

Vanderbilt Psychiatric Hospital

Electronic Medical Record: Unit Resource Manual

01/15/10 Vanderbilt Medical Center Systems Support Services

VPH: Electronic Medical Record• Why? Patient Safety – improved documentation

(comprehensive assessment, content, & legibility), Bar-Coded Med Administration

• What? HED for RN & MHS charting, StarPanel forms, & Admin Rx (med admin)

• When? Pilot on Adult I begins January 18th & all other units “Go Live” on February 1st

• How? Support Model: SSS staff will be on site to round 1st week of pilot & 2 weeks post – Go Live

Which Paper Documentation Processes will be continued?

Electronic Conversion expected Spring 2010Electronic Conversion expected Spring 2010• Respond Crisis Assessment • Social Work Psychosocial

Assessment & Progress Notes

• Teacher Progress Notes• Treatment Plan • Respond Crisis Intake

• Respond Crisis Assessment • Social Work Psychosocial

Assessment & Progress Notes

• Teacher Progress Notes• Treatment Plan • Respond Crisis Intake

Paper Format IndefinitelyPaper Format Indefinitely

• All Restraint & Seclusion Documentation

• Patient Belonging Sheet• Patient Discharge

Instructions Sheet

• All Restraint & Seclusion Documentation

• Patient Belonging Sheet• Patient Discharge

Instructions Sheet

HED Basics

Click on HED icon on the desktop & enter Racf ID (Id to enter CWS) opening to Care Organizer. Click

on HED to document.

Select your patient by clicking the arrow, then find them in

the drop down list.

A few pointers before we begin to Enter Data:•Pt demographics at the top of the screen (make sure you selected the correct pt) •Read the screen left -> right•Some tabs for charting are customized to your location •Make sure your Number lock is activated on your keyboard

Click the tab you want to enter data on. VPH view will contain 8 tabs: •VPH Assess/Intervention •VPH Vitals & I/O •MHS Observation •Protocols •VPH Education •Observation Precautions• Admin Rx•Pain

To begin entering data, click on the CHART button.

This will “open” your chart for data entry

If this tab has been previously charted on, only those fields that

contained data will re-open to be charted in.

Click Show All to see all fields available for data entry (this

should be done at least once a shift).

If needed, change

time here.

Some have drop downs with check boxes (more than one item may be selected). If an item is chosen in error, simply click again to de-select.

Begin entering data in the open fields.

Some will have a drop down with one selection

to be made

Some fields will have keyed in data entry

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As with this Transitional Checklist, some are a simple check that an item is done.

To enter general comments, click in the box and type in comments.

Note: 250 character max.

To make an annotation concerning a single entry, click

the “sticky note” on the corresponding line

Enter the comment (250 character max)

Notice the yellow check mark on the tab-this is reminding you there is unsaved data on this tab. Do NOT exit without saving or this data will be lost.

You will be taken to the Confirm Screen. Verify patient is correct, time of entry, and data correctly

entered.

Click Confirm to save data to chart.

Use the Back button to return to charting if mistakes are found.

Use the Discard button when you want to clear all data entered (use if

incorrect patient).

Copy/Modify/Move/Clear Functions-with

the chart “closed” click in the space between the date and time of the column selected.

Copy- Cannot be copied:•Numerical data•Annotations/ comments •Other people’s data •>30 hours old (works for same patient multiple days•All or nothing (can edit what you copied)•ECMO fs-only select items can be copied

Modify-Can modify single or multiple data points

at one time

Move-Can move entire

column of data to another time (useful if

you forgot to change your time on the chart

screen)

Clear-Can clear entire column or select

portions at one time (useful if you charted on

the wrong pt)

RN: VPH Assessment/Intervention Tab

RN: VPH Assessment/Intervention Tab: Note some fields are labeled with a job title and some with NO Job title 1. RN = RN to document. RN ONLY field = clinical assessment in the RN scope of practice or the drop down options are clinical assessment findings (not observations) as in MHS 2. MHS = MHS to document3. NO Job Title = Both RN & MHS can document with the same drop down options 4. This functionality is secured via the employee’s ID & HED Application Support Team

Safety Opportunity:

+ Psych pts are guarded with symptomology & do not share symptoms with all staff. + Clinical findings of RN & MHS can be viewed by each discipline. + RN can view ALL MHS documentation+ MHS views only RN’s documentation of General Behaviors, Hallucinations, & all of the Risk Assessment.

RN: Mental Status ExamAnnotate to provide more detailed information – see example below “CIA is after me!”Click on to open text field to type in your comment.

RN/MHS: Behavioral Intervention1. Select Intervention (“continue to monitor” should be routinely chosen w/ other interventions added as indicated) 2. Select patient’s response

RN/MHS: Risk Assessment Section

• In this section, you will assess & document clinical findings for: – Suicidal Behavior– Self Harmful Behavior– Violent Behavior

• Safety Opportunity: It is vital for RN’s & MHS’s to review the clinical findings & observations of their counterparts. Note: The pt may have shared Suicidal thoughts with MHS but NOT the RN!!!

RN: Risk Assessment – Suicidal Behavior1. Risk Factors for Suicide = “What places your patient at higher risk of acting on suicidal thoughts/ ideation?” (such as family hx, hopelessness, lives alone)2. Describe Plan is a narrative entry field3. Protective Factors = “What aspects of your patient’s life will help protect them from acting on suicidal thoughts/ideation?” 4. Safety Plan is REQUIRED on ALL patients that have identified risk for Suicide –drop down options include “continue to monitor”, “notify staff”, & “other w/ annotation”

•RN Assessment must ALWAYS address Risk Factors & Protective Factors for Suicide. (Even if NO suicidal ideation is present!!) •Patients with Risk Factors for Suicidal Behavior MUST have a Safety Plan & Interventions

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23

RN/MHS: Risk Assessment – Self-Harm1. Select Behaviors exhibited2. Interventions to be completed ONLY if Self-Harmful behaviors are present

Self Harmful behavior is either present or NOT. If NOT present, there is NOT a necessity to create a safety plan or

interventions. Suicidal & Violent Behaviors are more unpredictable & the presence of risk requires PROACTIVE

INTERVENTIONS to protect the pt & others.

RN: Risk Assessment - Violence

•Violence Risk & Risk Factors must be completed on ALL pts •Patients at Risk REQUIRE a Safety Plan & Interventions

RN: Precautions1. In the paper documentation workflow, the RN Documents level of PRECAUTIONS for the pt on the “Sticky Note”. This is where it will be documented in HED. 2. NOTE: Hourly documentation of mental health precautions are documented in the Observation Tab by either the RN or MHS (will cover in Precautions Observation Tab)

RN: Nutrition, Sleep, ADL’s, & ProtocolsNote: Detailed Protocol Documentation will be done in Protocols Tab

RN: Transport/Transfer1. To document transport/transfer to VUH for medical care & Court2. Document patient’s return to unit

Upon return to VPH, documentation of return should occur in this field

RN: Involuntary/Voluntary Section1. Document change in Legal Status (to involuntary status or to voluntary status) & the notification of RESPOND 2. Court Hearing & Findings3. Treatment Review Committee – document when requested & TRC determination when committee meeting is held

As this section will be used only occasionally, click “Show All” to

locate in the Gray Bar

RN: Falls Risk Assessment Complete with EACH RN ASSESSMENT1. Identify Risk Factors for Falling2. Assessment level of Risk – Standard or High 3. Document Risk Prevention – Standard Risk Interventions for ALL pts – High Risk pts = Standard + High Risk Interventions

RN: Pain Assessment (located in both Pain Assessment Tab & VPH

Assessment/Intervention Tab)

Complete EVERY SHIFT

Scroll down to enter Pain Relief Goal. Within 2 hours of

intervention, need to reassess for patient’s

response

RN: Medical Problem DocumentationDocument on an “as needed” basis determined by the patient’s clinical conditionConsult your nursing leaders for guidance on this type of documentation

RN: Medical Problem – WoundCreate wound site, document wound education, & assessment findings

Click on Start New Wound Site & complete pop-up box fields

Observation Precautions Tab

Observation Precautions Tab1. Select reason patient is on Observation Precautions (suicide, violence, elopement, disorientation) 2. Select observation status (1:1, Eyesight, Q 15 minutes)3. Monitoring a. Patient location b. Verbalizes Self Harm (yes or no) c. Harmful Behaviors (yes or no) d. Environment Check (yes or no)

Current Workflow of hourly documentation of observations on clipboard will occur here HOURLY

Observation Precaution Hourly Workflow:

Documenting on multiple patients in one charting session

• To document on a series of patients: 1. Complete the documentation on patient #12. Save & Confirm3. Go to top of HED screen to Patient Selection Drop

Down list & Click on Arrow4. Select the next patient you want to document on

this opens this patient’s medical record5. Click on the Observation Precaution Tab 6. Complete documentation on patient #27. Save & Confirm8. Repeat steps #3 - #7

VPH Vitals I&O Tab

VPH Vitals I&O Tab: Document Vital Signs, Height, Weight, Blood Sugars, & I&O’s in this tab

Vitals are shared result with

Protocols Tab

Height & Weight

VPH Protocols Tab

RN: Protocols Tab 3 Protocol Types: CIWA, COWS, CNSDP

Drug & Alcohol Withdraw Protocols

Symptom Scale Score: 1.Severity of symptoms & risk to patient2.Determines need for pharmacologic intervention

Three Protocols: 1.CIWA – alcohol withdraw2.COWS – opiate withdraw3.CNSDP – benzodiazepine withdraw

RN: CIWA Protocol (Score determines need for pharmacologic intervention. Add total score & enter. Document dose #, cumulative dose, & drug name here & administration documentation through Admin Rx)

RN: COWS ProtocolAdd COWS score & enter totalDocument which Drug is administered as per the ProtocolDocument Cumulative Dose & Dose #

RN: CNSDP Protocol Check for symptoms that are present, add #, document total score, then determine need for pharmacological intervention per Protocol & document dose # & cumulative dosage

Night Shift Documentation (11p-7a)

• Document sleep behaviors in the Assessment/Intervention Tab (if MHS documenting sleep will be documented in the MHS Observation Tab)

• Document Observation Precautions – Hourly• Document Pain Assessment • Document any episodic events as indicated• Document meds given in Admin Rx• Other documented on “as needed” basis

VPH Education Tab

RN/MHS: VPH Education 1. Patient Orientation to Hospital – complete at time of admission 2. Patient Orientation to Unit – complete at time of admission 3. Education – other, discharge, symptom relief, safety

These fields are addressed with each education

episode

RN/MHS: VPH Group Education1. Select Group Name2. Challenges 3. Participation4. Instruction Strategy5. Progress toward Treatment Goals

Child & Adol Units document in Peds

Group Section

StarPanel

VPH Nursing Admission HistoryVPH Episodic Event NoteVPH Treatment Review Committee Note

RN: Nursing Admission History

·Located in StarPanel see Actions Menu or Forms

·Demographic Data will Auto-populate

· Some Data will populates from previous admits

·Document Pt Search& Staff present

· Thorough Medical History Review

· Create Problem List · Save as Draft or Final

RN/MHS/SW: VPH Episodic Event Note

• This documentation format is used for detailed narrative descriptions of significant episodes

• Episode examples include events that led you to write a narrative progress note in the paper medical record

• Can be saved as a draft & later completed

• Save as Final when completed• Document can be viewed in

StarPanel All Documents (& soon OPC)

Hold Control key to select more

than one option

Name, Age, MR#, Gender

Auto-Populate

Click here to Save as

Final

OPC: To Review Nursing Data & MORE• Central location for

Multidisciplinary Data• RN mental status & risk

assessment data• Vital signs, Withdrawal

Protocol data, Labs• Hyperlinks to Progress

Notes, Consult Notes, Nursing Episodic Event Notes, & more

• Family Contact Info• Current Order Sheet PLUS

electronic MAR

OPC: RN Assessment Data Displayed

Treatment Review Committee •TRC Chair (Physician) is required to complete the TRC documentation•TRC Attendance – requires two MD’s, one staff member serving as the Patient’s Advocate, & two other clinical staff members (RN, SW, Pharmacist)•Documentation of patient’s or family member’s presence is required•Patient name, age, MR#, and gender will auto-populate•Name fields have a “name completer” functionality as you enter the first letters of the last name a list of employees will open – select the right individual

HED for Mental Health Specialists

MHS: Tab Documentation Overview Charting Responsibilities for Assigned Patients – Where do I chart it??

• MHS Observations Tab: Mood, behaviors, interventions, risks, ADL’s, food intake, sleep

• Observation Precautions Tab: HOURLY documentation for all patients on 1:1, Eyesight, & Close Observation

• Vitals/I&O’s Tab: Vitals, weights, intake & output (if ordered) = Vital/I&O’s Tab

• VPH Education Tab: Orientation to VPH & Unit when MHS completes upon admission (telephone rules, visitation)

• VPH Education Tab: Group documentation• Episodic Event Note: Narrative note on a patient event or episode

(i.e. outburst following phone call with family). In StarPanel • Night Shift: Sleep Documentation within MHS Observation tab,

Observation Precautions, other documentation as needed

MHS Observation Tab: 1. Clinical Observations 2. Behavioral Interventions 3. Risk Observations4. Nutrition Observations5. Sleep Observations6. Activities of Daily Living

MHS Observations Tab: OverviewNote some fields are labeled MHS (MHS to document), RN (RN to document or RN only field), or NO Job Title (either can document – shared options in drop down)

Safety Opportunity:

MHS can view displayed RN Documentation for

General Behavior, Hallucinations, & all Risk Documentation Fields.

This provides both information & a basis for

comparison.

Display PPT Slide #3

MHS Observations1. Document: See below for results to document2. Demonstrate: Annotation, Save, Confirm, Change Time 3. Explain: Need to review RN documentation for Safety Each Field has a drop

down list, can select more than one

descriptor, with ability to annotate

comments

Note: RN Documentatio

n

RN/MHS: Behavioral Intervention1. Document: Select Intervention (“continue to monitor” should be routinely chosen w/ other interventions added as indicated) 2. Document: Select patient’s response

RN/MHS: Risk Assessment Section

1. Explain: In this section, you will assess & document clinical findings for: 1. Suicidal Behavior2. Self Harmful Behavior3. Violent Behavior

2. Safety Opportunity: Reinforce need to review MHS’s clinical findings – pt may have shared Suicidal thoughts with RN but NOT the MHS!!!

MHS: Risk Observation1. Document: Suicidal Ideation verbalized 2. Document: Plan – yes(annotate) Add Annotation (“Hang myself”) 3. Document: Interventions – Emotional Support, Environment Check, & RN Notified (4. SSS Note: Emphasize importance of RN notification for patient safety – similar to critical vital sign reading – BP = 230/120 or T = 104.6!)

Note the RN’s

Findings

MHS: Risk Observation for Violence1. Document: Risk for Violence = threatening. Explain: If Risk for Violence is identified, Interventions must be activated & documented2. Document: Interventions = Emotional Support, Environment Check, & RN Notified

MHS: Other Observation Fields1. Document: Nutritional Observations 2. Document: Sleep Pattern & Intervention 3. Document: Activities of Daily Living

Enter % of Food Intake

Select from drop down for description

& Intervention

Observation Precautions Tab1. Document: Select reason patient is on Observation Precautions (suicide, violence, elopement, disorientation) 2. Document: Select observation status (1:1, Eyesight, Q 15 minutes)3. Document: Monitoring a. Patient location b. Verbalizes Self Harm (yes or no) c. Harmful Behaviors (yes or no) d. Environment Check (yes or no)

Next TAB!!!

Current Workflow of hourly documentation of observations on clipboard will occur here HOURLY

Demonstrate the ease of completing this on 3 pts in a row - document, save, select

next pt from drop-down & repeat

Observation Precaution Hourly Workflow:

Documenting on multiple patients in one charting session

• To document on a series of patients: 1. Complete the documentation on patient #12. Save & Confirm3. Go to top of HED screen to Patient Selection Drop

Down list & Click on Arrow4. Select the next patient you want to document on

this opens this patient’s medical record5. Click on the Observation Precaution Tab 6. Complete documentation on patient #27. Save & Confirm8. Repeat steps #3 - #7

VPH Vitals I&O Tab: 1. Document: Vital Signs, Height, & Weight

Vitals are shared result with

Protocols Tab

Height & Weight

MHS/RN: VPH Education 1. Document: VPH Orientation to Hospital – If MHS completes this education at time of admission, he/she should document 2. Document: VPH Unit Orientation – complete at time of admission

These fields are addressed with each education

episode

RN/MHS: VPH Group Education1. Document: - Select Group Name- Challenges - Participation- Instruction Strategy- Progress toward Treatment Goals (yes – will be most common answer in this field)

Child & Adol Units document in Peds

Group Section

RN/MHS/SW: VPH Episodic Event Note

• This documentation format is used for detailed narrative descriptions of significant episodes

• Episode examples include events that led you to write a narrative progress note in the paper medical record

• Can be saved as a draft & later completed

• Save as Final when completed• Document can be viewed in

StarPanel All Documents (& soon OPC)

Hold Control key to select more

than one option

Name, Age, MR#, Gender

Auto-Populate

Click here to Save as

Final