DISCHARGE and ADMISSION
New Pt Education program to document on every shift and to resolve all only on discharge.
What is Injoy?
Discussion: q shift, don’t resolve until discharge, etc
Prefilled/ Predetermined Flowsheet (FS) charting with 1 click.
What is Macro charting?
Circ Macro charting - put in accurate time , fill out question on device and “pt concerns”.
working on macro for Blood patch
Option to Individually create own Macro charting
To do q1-2min (Seizure), q5min (hemorrhage), q 15min (sepsis alert), q 1-2 min anaphylaxis, etc per order or protocol
What is required V/S documentation with corresponding emergency events?
ECH approved clinical resource app - “a premier evidence-based, physician-authored clinical decision support resource used by clinicians to make point-of-care decisions. It provides synthesized, constantly updated, and peer-reviewed medical information, covering 25+ specialties to improve patient care and reduce treatment variability. It requires a subscription for access.”
What is Uptodate?
Discussion: Other apps- AMION (real time on call MDs), Engage, Micromedex, Pharmacy links, Pt education, etc…
MD orders Tab that is on hold/needs activation but needs to be checked q shift in case MD orders were not released by mistake.
What is “Signed and held”?
Discussion: GDM orders not released. Release all except if orders are for emergencies- ie Hemorrhage, and inappropriate conditions.
Maternal Sepsis and Indwelling catheter Home Care materials to include with AVS printout
What are the required discharge teaching materials as appropriate?
Discussion: If any of above not included, must ask MD.
For Hypertension: MD will input pt home regimen
1)5 maternity specific considerations by AI on Fall Risk,2) Falling man icon and documenting intervention 3) non AI fall documentation (Hendricks ) requirement
1) What are Duramorph x 18hrs, PMAT score, Voided out, Mag infusion, PCA?
2) What is the “high fall risk” icon, and macro intervention for High fall risk, and standard fall risk.
3) What is Nurse‘s scoring documentation on Fall Risk (vs AI), and only done up to 12 hours of admission to the hospital.
Scan all bags required for bolus all at once, then edit exact ordered amount under amount box
How to document IVF bolus on MAR during Sepsis alert?
Discussion: To meet all Sepsis requirement from TOP
It replaced Lippincott as a subscription based resource for policies/procedures not included in ECH own PolicyStat
What is EBSCO?
Discussion: example of protocol not in PolicyStat- Jada, Bakri.
Where to look for PolicyStat (don’t look for Clinical policies/procedures in Elemeno).
Charting pt care on high emotional, psychosocial need
What is “psychosocial” FS and notes
Discussion: “workload Acuity” score
Tabs :Care Everywhere (PAMF and SMP group),Chart review/media (ECWG and Independent practice MDs) or “search Icon“
Or hard copy in chart
What are the places to search for Pt History?
Discussion: when unable to find prenatal lab history like HBSAG and what is necessary action.
Shortcut to seeing all required documentation for the shift.
What is “Required doc“ tab
Documentation of critical lab value received by phone call or critical BG value by POCT
What is Critical lab required documentation? include no intervention Or no action as per per pt condition or protocol.
App where you can find MBU specific meeting minutes, EPDS in other languages, etc
What is Elemeno?
Discuss - don’t get policies and protocols from Elemeno
One of the ways to contact a physician to report a change of condition aside from phone call. Also to communicate with other personnel/department pertaining to the pt, ie pharmacy discharge meds..
What is Secure Chat?
Discuss do’s and don’ts, when to use, and tips on adding people in chat.
Epic Tab that organizes documentation for admission and discharge
What is Navigator tab?
Discussion:
Helpful to preview AVS for RX and Pharmacy
Check out admission navigator tab for admission
Required documentation on use of Interpreter
What is Communication F/S Interpreter?
Discussion: where to get the name and number of interpreter
V/S machine “interval“, “admit pt” buttons
What is V/S machine auto function?
Discussion: set interval settings during emergencies for auto BP, HR readings. Also ”admit pt” setting should auto populate FS in Epic
Tab to Print pt labels and forms
What is Print form tab?
Reason why maternity shouldn’t go to Flowsheet tab while pt in L&D but to use Summary tab instead when checking on pt’s vitals.
what is “disabled“ Flowsheet?
EPIC FS is not available to chart on if another person is concurrently on same page.
Section in pt chart that shows Time and date of admission among other highlights.
What is Story Board?
Discussion: time and date - for Hendricks (Chart only to 12 hrs of admission),”3day” PP protocol for c diff, sepsis, etc
Also on Story Board- highlighted EPDS #10 positive score, hemorrhage risk, etc
Required documentation to assess risk for pressure ulcer
What is Braden? Chart intervention q 2hrs for score of 18 and below. See “definitions“ right side of FS
1)Bringing an extra computer to the room during emergency 2)QBL and I&O
1)What can help with charting, MAR access, check or input MD orders, check protocols- all done simultaneously for efficiency during emergencies 2) what is QBL wrenched in to FS?
App to report and request service for any malfunctioning equipment?
What is Service request
Active LDAs Flowsheet or “edit” charting
What is required documentation for LDAs?
Discuss what to do if LDAs are not d/c’d in epic? Ie epidural cath- D/C LDAs, write on note box “not found on assessment, unknown time of date of removal”. Should not discharge pt with active LDA unless pt actually going home with LDA.