Nursing Documentation
The place in Epic that an IV is documented.
What is in IV Access in Nursing Documentation or in Flowsheets and LDA Avatar?
Actions taken when there is a positive SDOH question.
What is add SDOH information to AVS if 1 positive and order for Social Work Consult and email social work if 2+ positives?
The documentation when one nurse gives report to another nurse at shift change, change of assignment, prior to going on break, etc.
What is nurse hand-off (documented in Nursing Documentation)?
The location where blood tubes are labeled after collection
What is at the patient bedside?
The policy "Medications Dispensed from the Emergency Department" requires this person to fill out the medication label.
Who is the ordering provider?
This is what is documented for an eye irrigation and where to find it.
What is the pH prior to irrigation, the eye(s) irrigated, the amount and type of solution irrigated with, the pH 15 minutes after irrigation?
And what is in Nursing Documentation under Ear/Eye Procedure?
The questions asked while triaging a patient with a nosebleed.
What is onset of nosebleed, amount of blood lost, use of blood thinners/ aspirin, any history of nasal or sinus trauma or surgery, use of Afrin/ held pressure when bleed began, history of nosebleeds?
The frequency vital signs should be taken for ED patients.
What is every 4 hours or more often if abnormal, before and after narcotics, BP meds, ativan, before and during cosopt, etc?
You open new bottles for the glucometer QC, this is what you should place on the bottles.
The policy "Treatment of Patients with Human or Animal Bite in Emergency Room" discusses submission of this Department of Public Health form.
What is the Report of Bite by a Domestic Animal Form?
This is what is documented during a Time Out for a procedure in the ED (major points of documentation).
What is the consent confirmation, the name of the procedure, the site being marked, that the time-out occurred, and start/ stop time?
Triage note for patient that arrives with nerf gun injury.
What is time of injury, vision changes since injury, pain in eye or headache, ocular history, pupil assessment, use of eye drops/ medication for ocular conditions?
The documentation required of a nurse assigned to care for a patient in the bay area.
What is nursing update in nursing documentation, vital signs every 4 hours or more frequently if abnormal or giving medications that require VS, events, comfort measures, updating patient and family?
The place on Epic with information about lab tube color and information about the specimen.
What is Resources > Laboratory Handbook > MEE?
The policy "Emergency Department Hypertension Guideline" requires this action from the RN when patient's BP is > systolic of 120 and / or diastolic of 180.
What is document in EHR, document history of HTN, reconcile home medications, document if any BP-related medications were taken today, assess for history of, or current, chest pain, SOB, HA accompanied by confusion and blurred vision, N/V, severe anxiety, and history of aneurysm, and notify MD?
The documentation/ actions required when admitting a patient to the adult inpatient unit.
What is call registration (nursing supervisor afterhours) to notify of admission, pend admit the patient, basic assessment, IV access, patient belongings, healthcare proxy, print stickers, set up chart with last name of patient and admitting MD, OSH paperwork in chart, and nursing report with documentation of who report was given to?
The actions taken in triage when patient arrives with an active Tonsil Bleed.
What is ask about date of surgery and surgeon, NPO status, amount of blood loss, onset of bleeding episode, airway/ throat assessment, current weight on scale, IV access, set up stretcher with suctioning?
The action taken prior to and following administration of narcotics.
What is take vital signs and document level of pain before and after administration of narcotics?
The number of Type and Screen samples that need to be sent to the lab for a patient who has no records in our EHR.
What is 2 samples from 2 different sites with documented separate times for the draws?
The policy "Patient Triage and Classification Policy" describes conditions often seen in the MEE ED to categorize triage levels 1, 2, and 3.
Triage Category 1 known or suspected conditions include these:
Acute Angle Closure Glaucoma
Bleeding, severe
Burn, chemical or facial
CRAO
Chest pain
Endophthalmitis
Epiglottis
Epistaxis
Facial trauma with respiratory distress
FB in larynx or esophagus
Lacerations, severe
Open globe
Orbital compartment syndrome
Respiratory distress
Stroke-like symptoms
Temporal arteritis
Vision loss, sudden- new onset
The required documentation during triage.
What is: Travel/Exp/Symptom Screen, ED Triage Note, Chief Complaint, Airway, Vital Signs, Eye Exam, Allergies, Home Medications, Problem List, Med/Surg Hx, Social, Hx, Immunizations, OB/GYN, Abuse, Suicide Screening, Nutrition, Morse Fall Risk, SDOH, Delirium Triage Screening, Violence Risk Assessment (ABRAT), Weapon Screening, and Triage Comp/ Acuity?
Triage note for patient that arrived from an outside hospital with an open globe includes this information.
What is time of injury, mechanism of injury, imaging performed (if disc was uploaded at MEE), NPO status, medications given at OSH with time and dose, objective observations of eye (pupil description/ obvious globe deformity), ocular history or history of ocular surgery?
Your assigned to a patient in the bay that suddenly complains of chest pain, talk us through the next steps in their care.
What is notify EP (or attending/ resident if no EP), VS, EKG, cardiac monitor, IV access, travel meds in omnicell, transfer to MGH, report to MGH and documentation of events in epic?
The correct procedure to collect blood cultures.
What is:
1. Cleanse the diaphragm of each blood culture bottle with an (separate) alcohol wipe, allow to dry, and repeat
2. Cleanse the patient's site with alcohol and allow to dry
3. Cleanse the patent's site with chlorhexidine and allow to dry (do not use chlorhexidine of patient less than 2 months of age)
do not touch the site unless you use a sterile glove
always draw the blue bottle first and then the red bottle (for adults)
two sets of blood cultures are needed for adults but need to be drawn from 2 different sites
patients less than 6 years of age only one bottle is needed (pink bottle)
Of course, we have to identify the patient with 2 identifiers and label the specimens at the bedside.
For the full policy please look in Ellucid under Mass General and search for blood culture.
The policy "Reporting a Weapon Related Injury" discusses completing and mailing this form when a patient presents with any weapon related injury that resulted from an act of violence or any powder burn (i.e., fireworks).
What is a Weapon Related Injury Surveillance System (WRISS) Form?