OBJECTIVES: HED Nursing Documentation
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Transcript of OBJECTIVES: HED Nursing Documentation
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Document Interventions, Assessments
Set Preferences & Create Assignment
View Confirming Med Orders
Commit to use HED system safety
checks
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Beginning of shift or change level of
care
Items in ALL CAPS on gray bar charted
each shift
Line Manage charted each shift
Vanderbilt charts to Standards & only
denotes variances
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Brief synopsis of your shift before Shift change
Include major clinical events & information
For oncoming RN..does not replace face-to-face report
Prints on OPC as reference for nurse during shift
Temp controlled with Tylenol. No further nausea. O2
sats improved on nasal cannula.
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Explore StarPanel.. EMR◦ Look up test results and documents
◦ Complete Admission History form
◦ Assign a Pathway (Plan of Care)
Enter orders in HEO/Wiz… CPOE◦ Enter Nursing Orders for New Admission
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3 Sections of Admission Data
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Duplicate Name alert
Inpatient Admission
Observation Admission (short term stay) Patient has discharge orders
Pre-Orders entered by Provider for Chg Nurse or MR to playback today
P
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Processing of OrdersProcessing of Orders
Orders & Reqs print to Medical Receptionist (MR) and
placed in unit appropriate area
MR: Notifies RN of STAT Orders and Labs
MR: Notifies Department of Other Tests
RN: Acknowledges Orders online
Emergency Departments: Order do NOT print. Lab
Requisitions generate to printer closest to pt’s room
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Steps to Acknowledge Orders
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