Vanderbilt Psychiatric Hospital

1. Vanderbilt Psychiatric Hospital Electronic Medical Record: Unit Resource Manual Vanderbilt Medical Center Systems Support Services

2. 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

3. Which Paper Documentation Processes will be continued? Electronic Conversion expected Spring 2010 Paper Format Indefinitely All Restraint & Seclusion Documentation Patient Belonging Sheet Patient Discharge Instructions Sheet • Respond Crisis Assessment • Social Work Psychosocial Assessment & Progress Notes • Teacher Progress Notes • Treatment Plan • Respond Crisis Intake

4. HED Basics

5. Select your patient by clicking the arrow, then find them in the drop down list. Click on HED icon on the desktop & enter Racf ID (Id to enter CWS) opening to Care Organizer. Click on HED to document.

6. 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 • 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

7. If needed, change time here. If this tab has been previously charted on, only those fields that contained data will re-open to be charted in. Click Show Allto see all fields available for data entry (this should be done at least once a shift). Some will have a drop down with one selection to be made 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. 0.4 Some fields will have keyed in data entry 100 Begin entering data in the open fields.

8. 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) “Sticky note will turn yellow. Hover over it to see the comment. As with this Transitional Checklist, some are a simple check that an item is done.

9. Once data entry is complete, you are ready save. 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.

10. Click Confirm to save data to chart. Use the Discard button when you want to clear all data entered (use if incorrect patient). Use the Back button to return to charting if mistakes are found. You will be taken to the Confirm Screen. Verify patient is correct, time of entry, and data correctly entered.

11. Copy- • Cannot be copied: • Numerical data • Annotations/ comments • Other people’s data • >30 hours old (worksfor 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 Clear- Can clear entire column or select portions at one time (useful if you charted on the wrong pt) Move- Can move entire column of data to another time (useful if you forgot to change your time on the chart screen) Copy/Modify/Move/Clear Functions-with the chart “closed” click in the space between the date and time of the column selected.

12. RN: VPH Assessment/Intervention Tab

13. 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.

14. 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.

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

16. 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!!!

17. 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” 1 2 3 • 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

18. 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.

19. RN: Risk Assessment - Violence • Violence Risk & Risk Factors must be completed on ALL pts • Patients at Risk REQUIREa Safety Plan & Interventions

20. 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)

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

22. RN: Transport/Transfer1. Todocument 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

23. 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

24. 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

25. 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

26. 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

27. RN: Medical Problem – WoundCreate wound site, document wound education, & assessment findings Click on Start New Wound Site & complete pop-up box fields

28. Observation Precautions Tab

29. 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

30. Observation Precaution Hourly Workflow: Documenting on multiple patients in one charting session • To document on a series of patients: • Complete the documentation on patient #1 • Save & Confirm • Go to top of HED screen to Patient Selection Drop Down list & Click on Arrow • Select the next patient you want to document on this opens this patient’s medical record • Click on the Observation Precaution Tab • Complete documentation on patient #2 • Save & Confirm • Repeat steps #3 - #7

31. VPH Vitals I&O Tab

32. 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

33. VPH Protocols Tab

34. RN: Protocols Tab 3 Protocol Types: CIWA, COWS, CNSDP Drug & Alcohol Withdraw Protocols Symptom Scale Score: Severity of symptoms & risk to patient Determines need for pharmacologic intervention Three Protocols: CIWA – alcohol withdraw COWS – opiate withdraw CNSDP – benzodiazepine withdraw

35. 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)

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

37. 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

38. 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

39. VPH Education Tab

40. 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

41. 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

42. StarPanel VPH Nursing Admission History VPH Episodic Event Note VPH Treatment Review Committee Note

43. 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

44. 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) Name, Age, MR#, Gender Auto-Populate Hold Control key to select more than one option Click here to Save as Final

45. 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

46. OPC: RN Assessment Data Displayed

47. 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

48. HED for Mental Health Specialists

49. 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

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