Electronic Clinical Documentation Training Materials

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    Perinatal staff

    Registered Nurses and Registered Midwives

    This video demonstrates triage documentation in the OB Patient History and Triage Powerform, and in Interactive View.

    High-level overview of admission documentation/triage assessment.

    This video will review the workflow of adding, reviewing and maintaining an accurate list of current Pregnancy Risk Factors with a nursing focused workflow.

    This video demonstrates how to document Obstetrical History.

    This video will outline how to add a pregnancy in PowerChart Maternity.

    Brief overview of intake and output in Perinatal.

    IUPC, FECG and Catheter Induction

    A brief overview of basic labour assessment, including Epidural Insertion and initial assessment.

    A review of second stage documentation.

    This will describe forceps/vacuum documentation as well as delivery documentation.

    This will walk users through Auto Text Copy-then inserting the newborn head-to-toe autotext into the Newborn Admission Note.

    This video will provide an overview of result copying twins after delivery, and completing the growth chart PowerForm.

    This video will demonstrate the workflow of a how to review the newborn chart and document the results of hearing screening performed in hospital.

    How to start the partogram, as well as a basic overview of purpose and how to use.

    Nursing Unit Assistants

    This video will walk through how to preregister an impending delivery of a liveborn infant.

    Mental Health and Substance Use

    Daily Documentation

    Review of completing tasks in care compass. Covers documenting MHSU admission documentation.

    Review of customizations you can make to the MHSU workflow page. This will also show you helpful components to MHSU that are on the page.

    Review of iView Documentation. MHSU iView bands, customizing the bands, documenting a mental status assessment, adding comments, modifying and un-charting information and adding and viewing annotations.

    Review of safety and attendance and individual observation record documentation.

    Care Transitions and Communication

    Review of where to document hand-off communication in iView.

    Review of the documentation required for transfers within the hospital.

    Review of where to document inter-facility transfers.

    Review of where to document all the necessary information at discharge in Cerner.

    Patient-Related Incidents

    Review of where to document a fall in Cerner.

    Includes information on where to document a suicide attempt or incident of self-harm.

    Completing the suicide screener ‘is path warm’ Completing a suicide assessment Posting a suicide alert ‘danger to self’ in the banner bar Removing a suicide alert from the banner bar.

    A review of where to document when a violent incident has occurred.

    History of Violence Documentation

    Completing a violence screen and the VBACT Documenting a historical risk of violence.

    How to place a violence alert.

    Review of behavioral care plan documentation.

    Perioperative

    Workflow

    Review of PowerChart navigation and workflow for the PAC nurse.

    Review of PowerChart navigation and workflow for the Surgical Day Care nurse.

    Review of PowerChart navigation and workflow for the OR nurse.

    Review of PowerChart navigation and workflow for the PACU nurse.

    How to create a SDC Patient List.

    Documentation

    Review of how to create a chart annotation in PowerChart.

    Review Procedural Sedation Documentation in iView.

    Blood Products

    Review of how to create a chart annotation in PowerChart.

    Additional resources are available on the CDH Periop Resources SharePoint:

    • Resources and Quick Reference guide you will find cover the following topics.
    • ACU Admission Documentation
    • Preiop Clindoc Scope
    • BMDI association Draeger devices
    • Choosing correct pre procedure powerform
    • Receiving inpatients and ER patients for surgical or endo procedures
    • Review and modify pre procedure assessment
    • Making a Patient Lost for Nurses and Physicians
    • Update procedure history

    Pediatrics

    This is an overview of the clinical assessment components on several workflow pages that contain basic head-to-toe documentation done by clinicians. It describes the trending abilities and how pages can be set up.

    This is an overview of the admission tasks present for pediatric patients admitted to the ward. It shows how to use them from CareCompass or from within the patient’s chart using Activities and Interventions.

    This is a description of the Pediatric Early Warning System workflow from documentation to alert to documentation in PEWS task.

    This video demonstrates review of the Handoff page and the many components there and their usefulness in finding out about your patient at transitions of care, including shift handoff and transfers to other places in the hospital.

    This video demonstrates the use of the discharge planning admission task, the discharge planning – ongoing task, and the Discharge Workflow page from the nurse’s point of view.

    Critical Care

    Admission

    Review of Critical Care RN Handoff and Critical Care RN Manage Workflow Pages.

    Review of Admissions tasks and documentation through CareCompass.

    Daily Documentation

    Review of how to associate bedside monitor to PowerChart.

    This is an overview of the clinical assessment components on several workflow pages that contain basic head to toe documentation done by clinicians. It describes the trending abilities and how pages can be set up.

    How to document patient information from an associate monitor.

    Critical Care Daily Documentation: Safety Checklist and Bed Safety.

    Pain and the rest.

    ADLs.

    Critical care systems assessment.

     Lines and devices.

    Intakes and outputs.

    Documenting Team Communication, Provider, Clinician, Informal Team communication.

    Narrative documentation: Chart Annotations.

    Transitions in Care

    Transfer of care on shift change.

    Transfer of care, intra-facility transfers, transports within the site.

    Transfer of Care, inter-facility transfer to other Island Health Site.

    Transfer to OR

    CCOT

    Review of CCOT initial consultation, CCOT on-Site assessment and actions, and CCOT follow-up PowerForms.

    Blood Products

    How to document the administration of blood product.

    Documenting a transfusion reaction.

    Procedure

    Review of Critical Care procedure documentation.

    Discharge and Death

    Discharge Documentation

    Documenting Death

    CareAware

    A high-level overview of the CareAware Critical Care application.

    History of Violence Documentation

    Completing a violence screen and the VBACT, documenting a historical risk of violence.

    Placing a violence alert.

    Documenting a behavioral care plan.

    Provider

    Review of the Internal Medicine Admit/Consult and Round/Manage workflow pages and the associated quick links.

    Emergency Services and Trauma

    Daily Documentation and Device Set-Up

    How to navigate the tracking list, manage patients in the tracking list, access laboratory and diagnostic results within the tracking list, and check-in and check out of the tracking list.

    Review patient information within the EHR.

    How to associate the bedside monitor to your patients EHR.

    Head-to-toe (adult) assessment in ED.

    Documenting a patient with a single system concern.

    Narrative test as Chat Annotation in iView.

    How to create Dynamic Groups for documentation in iView.

    Review of Pediatric Early Warning System (PEWS) in the ED.

    Procedures

    How to document nursing procedures of catheterization, chest tubes etc.

    How to document Procedural Sedation in iView.

    How to document Oral, Nasopharyngeal and ET Tubes in iView.

    Procedures

    How to document nursing procedures of catheterization, chest tubes etc.

    How to document Procedural Sedation in iView.

    How to document Oral, Nasopharyngeal and ET Tubes in iView.

    Blood Products

    How to document the administration of blood product.

    History of Violence Documentation

    How to complete a violence screen and the VBACT Documenting a historical risk of violence and a reassessment.

    Placing a violence alert.

    Documenting a behavioral care plan.

    Death Documentation

    Review of death documentation.

    Medical / Surgical

    Daily Documentation

    Review of systems assessment documentation in interactive view in Cerner PowerChart.

    Review of the Handoff page, the many components there and their usefulness in finding out about your patient at transitions of care. Includes shift handoff and transfers to other places in the hospital.

    How to create a chart annotation in Cerner Powerchart.

    An overview of the clinical assessment components on several workflow pages that contain basic head-to-toe documentation done by clinicians. It describes the trending abilities and how pages can be set up.

    Review of how to associate bedside monitor to PowerChart.

    Review how to document patient information from an associate monitor.

    Admission, Discharge, Transfer and Death

    Review required EHR documentation for Adult Med/Surg.

    Review of Transitions in Care: Transfer to OR.

    Review of the electronic documentation required when transferring a patient to another Island Health Facility or site.

    Demonstration of the discharge planning admission task, the discharge planning – ongoing task, and the Discharge Workflow page from the nurse’s point of view.

    Review Documentation of Death in Cerner PowerChart.

    History of Violence Documentation

    Completing a violence screen and the VBACT Documenting a historical risk of violence.

    Placing a violence alert.

    Documenting a behavioral care plan.

    Blood Transfusion

    How to document the administration of blood product.

    Documenting a transfusion reaction.

    Printing

    Review of how to print MOST and Active Allergies, nursing unit list location list and Med rec.

    Medical Record Request

    How to complete a Medical Record Request.