Legal/Policy
If it wasn't documented, it wasn't this
Done
This is how you access the mPages?
There is a button at the top of the Cerner bar called “mPage Hub”
My patient is incontinent and has a foley catheter. I provided peri care and foley care with a linen change. I charted it here.
“Urinary Catheter Care Done” under Hygiene ADLS
The process where a nurse transfers responsibility for specific tasks to another qualified healthcare professional
Delegation
Changes in HR, RR, SBP, 02 sat and oxygen needs, mental status changes
Reportable Values
This should be done when the PCA notices there is no output from the drain.
Document zero and notify the nurse per delegation.
The “Daily Mobility Tracker” mPage helps to keep track of progress towards this BMAT 4 ambulation goal.
100ft per day
I removed my patients IV after the nurse asked me to do so to prep for discharge. I charted it here.
Lines Tubes and Drains under Peripheral IV
making eye contact, paying attention, and asking questions are examples of ...
Active listening
Copy and pasting documentation
What is not permissible per policy
PCAs can go through disciplinary action through the State Board for Nurses (potential loss of CNA certification) by documenting this.
Fraud or deceitful documentation, record, and health documents.
The PCA can check central lines that require a CHG bath every 24hours here.
The Facility Line mPage
The nurse is concerned my patient is having urinary retention. I bladder scanned them and found that they have 450mL in their bladder. I charted the residual here after I notified the RN
Random Bladder Volume under “Bladder Scan/Postvoid Residual”
Ensures messages are understood by verbal feedback and confirmation from both the sender and the receive.
Closed loop communication
An accurate and legal record of patient care, ensuring continuity of care among health care providers, and protecting legal rights of the patient and caregiver.
The purpose of documentation
According to governing regulatory bodies and banner Policy, record of treatments and response to treatment must be documented during this time.
As soon as possible after the occurrence.
Patients should use an incentive spirometer 10 times every hour while awake. The PCA can track through this mPage
Hospital acquired pneumonia - mPage shows how many times each patient on the floor has had oral care, used an IS, or had head of bed elevated.
I accidentally did not accept my glucometer result. Good thing I can chart it here in Cerner.
POCT Glucose Glucometer Capillary under Diabetes Flowsheet (You may need to add this to your view)
A supportive and respectful environment where team members feel valued and work together to achieve success.
Mutual Respect and Trust
Includes but is not limited to VS, I &0, bowel and bladder habits, food, and fluid consumption, patient mobility, and repositioning, observations and care provided (bathing, grooming, feeding etc).
Information a PCA should document
The PCA documents oral intake before the patient drink anything.
Deceit or false documentation
The “Facility Lines” mPage shows all patients with a port, PICC line, dialysis access, midline, or IJ. The PCA does not need to perform a CHG bath on this line.
midline
My patient has SCDs ordered, and they are in place. When I took them off after helping them to the chair. I charted the removal here.
Antiembolism Device Removal Reason under Activities of Daily Living
Improved patient outcomes, increased efficiency, enhanced staff moral and retention and improved patient safety.
The benefits of teamwork
Provides scope and standards of practice and care guidelines
Wyoming State board of Nursing and Banner Policy