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Physical Assessment Documentation Change Tutorial. PowerChart—Clinical Documentation Summer 2008. Physical Assessment Documentation Change Objectives. Define rationale for changes; Demonstrate how the changes to the physical assessment form support efficient and effective documentation;

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physical assessment documentation change tutorial

Physical Assessment Documentation ChangeTutorial

PowerChart—Clinical Documentation

Summer 2008

physical assessment documentation change objectives
Physical Assessment Documentation Change Objectives
  • Define rationale for changes;
  • Demonstrate how the changes to the physical assessment form support efficient and effective documentation;
  • Explain how to use the revised edema and skin integrity grids.
rationale for the change
Rationale for the Change
  • The physical assessment form must capture positive and negative findings.
  • The form should make it easier for the nurse to identify changes in patient status.
  • These changes will support future system enhancements and the continued use of charting by exception (CBE).
charting by exception cbe
Charting By Exception (CBE)
  • Charting by Exception is a streamlined format that is used to enable nurses to quickly and completely chart findings that match or deviate from “Defined Normal” assessment parameters.
charting by exception cbe1
Charting By Exception (CBE)
  • Each body system has a definition of “Defined Normal” located in the window (aka “Genview”) at the top of each body system form and/or section.
  • “WDL” (within defined limits) specifies the finding for each parameter that is considered normal.
  • Deviations from normal are documented using “WDL Except” and the exceptions must be specified.
physical assessment form changes
Physical Assessment Form Changes:
  • All “defined normal” parameters default to “WDL.”
  • This implies that the parameters of the system that were opened, were assessed, and found to be within defined limits.
  • If nothing is changed and the form is signed, the “defined normal” parameters for the system will indicate WDL on the flowsheet.
slide7

Note each defined parameter defaults to “WDL”; also note that last charted value (LCV) will appear in the “Genview”.

slide8

If no changes are made to the default settings of “WDL” when the physical assessment is signed, it will indicate that all defined parameters have been assessed and have been found to be “WDL” of the defined normal of the body system that has been assessed.

nursing flowsheet
Nursing Flowsheet:

Note that all “WDL” parameters will post to the nursing flowsheet when documentation is signed.

physical assessment form changes cont
Physical Assessment Form Changes (cont.):
  • “WDL Except” and “Additional Parameters” remain unchanged.
  • “Unable to Assess” has been added to each defined parameter in each body system; if selected, a reason “Unable to Assess” is required.
slide11

Selecting “Unable to Assess” will open the “Reason Unable to Assess.” (This is a required field and must be completed prior to signing the documentation).

charting a physical assessment
The following slides will demonstrate documentation on the physical assessment related to the changes that are being implemented.Charting a Physical Assessment
slide15

If no changes are made to the default settings of “WDL” when the physical assessment is signed, it will indicate that all defined parameters have been assessed and have been found to be “WDL” of the defined normal of the body system that has been assessed.

slide16

Selecting “Unable to Assess” will open the “Reason Unable to Assess.” (This is a required field and must be completed prior to signing the documentation).

slide17

Selecting “WDL Except” will open additional conditional fields, which are required, to document assessment findings.

slide18

Note: “LOC” & “Gross Movement” were selected as “WDL Except.” These fields will turn white to allow documentation, and are required, prior to signing.

slide19

Note: If “WDL Except” is not selected, all remaining fields will remain “grey” or “dithered”; documentation can not occur in these fields.

slide21

“WDL” will be the default for each body system when the assessment section/form opens. Signing the form, indicates that all “Defined Normal” parameters have been assessed.

Click on the “Back Arrow” to continue.

slide22

After documentation on the physical assessment form has been completed, sign the form. Click on the “Check Mark” now to sign and continue.

slide23

Selecting the “Nursing” Tab allows all disciplines to review documentation.

Select “Neurological” from the navigator to continue.

slide25

Note that “WDL” will now post to the “Nursing” flowsheet. This allows other disciplines to determine which parameters have been assessed related to “Defined Normal” definitions.

documenting a selected assessment
Documenting a “Selected Assessment”
  • “Selected Assessment” occurs when only one or some of the “Defined Normal” parameters have been assessed.
  • “Selected Assessment” may occur as part of the plan of care or per a physician order, such as a frequent assessment of “LOC” on the Neurological Form.
slide28

Note that clicking on the eraser icon will remove the “WDL” defaults. It also removes information from the “Genview” at the top of the form. (When the form is opened for future documentation, the “WDL” and “Genview” will be present). Prior to clicking on the eraser icon, review the “Genview” information as needed.

Under “LOC” select “WDL Except” to continue.

slide29

If “LOC” was previously charted, when “WDL Except” is selected; last charted value (LCV) pulls forward. Verify that the LCV information is correct, change the LCV information, or chart new information. Then, sign the form to save the information.

slide30

Note on the “Nursing” flowsheet that when a “Selected Assessment” is documented, only the parameter(s) assessed and documented will post.

form change edema grid
Form Change: Edema Grid
  • The edema documentation grid has been changed; multiple rows have been added to eliminate the need to add new rows.
  • Review the reference text for appropriate definitions of edema, generalized edema and limited use of the term “anasarca” for end-stage system failure.
slide33

“Edema” EBP reference text is available by right clicking the mouse in any of the column headers, or in the “Generalized Edema”, “Anasarca” field. Note that the drop down window will appear, select “Reference Text”.

Click on “Reference Text” now to continue.

slide34

“Edema” and “Anasarca” reference text.

Click “OK” to close reference text and continue.

slide35

Note that the box for bilateral ankle edema is a single select “Alpha” field.

Next to “Ankle” click on the box under “Bilateral” to continue.

slide36

The “Result Details” window for “Bilateral” will open. Note the selection options.

Click on “OK” to continue.

slide37

“Girth Measurement has been added to “Edema”. Note that the information is entered in “Inches” and auto-calculates to “cm”.

slide39

Note that all of the other “Defined Normal” parameters are defaulted to “WDL.” Signing the form now indicates that all of the parameters were assessed.

Click on the “Check Mark” to sign the form and continue.

slide40

Note the documentation on the “Nursing” flowsheet. “Edema” and “Girth Measurements” are the only defined parameters that were not within the “Defined Normal” parameter. The documentation supports that all parameters were assessed, which is indicated by “WDL”.

skin assessment documentation
Skin Assessment Documentation
  • The skin assessment documentation grid has been changed; multiple rows have been added to eliminate the need to add new rows.
slide43

“Skin” assessment reference text is available by right clicking the mouse in any of the column headers, note that the drop down window will appear, select “Reference Text”.

Click on “Reference Text” now to continue.

slide44

“Skin Integrity” reference text.

Click “OK” to close reference text and continue

slide45

Note the row and column headings. Each box allows for multiple selections.

Select the box next to “Skin Abnormality 1”; under “Body Part” to continue.

slide46

Note that the “Result Details” window for “Body Part” will open, allowing for multiple select documentation.

Click “OK” to continue

slide48

Note the multiple selections available for “Spatial Location”.

Click on “OK” to continue.

slide49

Clicking on the box under “Abnormal Skin Color” will open this charting window. Note the available selections.

Click “OK” to continue

slide50

Clicking on the box under “Skin Conditions” will open this charting window. Note the available selections.

Click “OK” to continue

slide51

Clicking on the box under “Skin Temperature” will open this charting window. Note the available selections.

Click “OK” to continue.

slide53

Note that all other defined parameters have defaulted to “WDL.”

Signing the form indicates that these parameters have been assessed and are within the “Defined Normal” for the body systems.

Click on the “Check Mark” now to sign the form and continue.

review of documentation changes
Review of Documentation Changes
  • All of the body systems’ “defined normal” parameters will default to “WDL.”
  • Signing the body system form without changing the default indicates that each “Defined Normal” parameter was assessed and found to be “Within Defined Limits.”
  • Edema and Skin Assessment documentation is completed on a grid.
slide56

To practice the changes to documentation, go to

“Cerner Training”:

User Name: Train

Password: Train

Contact your site coordinator with any additional questions, related to the training environment.

You have successfully completed the “Physical Assessment Documentation” Tutorial. Click on “The End” to Exit.