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Nursing Documentation

What's New in Nursing Documentation

August 5, 2014

  • NICU/NBN
    • The “Nutrition” section is no longer chartable thereare new charting fields under “Breast Milk &/or Formula”
    • Newborn Nursery Flowsheet > Ongoing Teaching has been redesigned
  • VUH
    • Vitals I&O > Intakes – Ketamine has been added
  • All VUMC
    • Added Left nare and Right nare to Airway Securement result
    • Added new result for “Study Drug” to IV Med Drips section
    • Changes to the Catheter Start details
      • All catheters will require documentation in the Catheter Insertion section
      •  The ED/Inpt insertion section will only be documented if the catheter was started in VUMC ED or Inpatient unit

July 29, 2014


July 22, 2014

  • All VUMC
    • Education Record > Pulmonary Education – Adding 4 options
    • Adding Mosby’s Nursing Consult to the "Links" menu in HED
    • Med List Tool (MLT) is embedded in provider  H&P forms
  • VUH ICU
    • EVD Site Dressing and Lumbar Drain Site Dressing change
    • “Ventilator Mode” changes in HED
    • Beginning July 22, 2014 ADULT Respiratory Care will document ventilator data in HED
    • Respiratory Care will  have a new tab (Respiratory Care)

July 15, 2014

  • VUH ICU
    • HED changes-The CRRT “volume to pull” calculation format is changing to simplify data entry and decrease the potential for errors.
    • HEO changes- CRRT orders can now be grouped and viewed on one screen.    This is done through use of the display button at the bottom of the current orders screen.
    • New medications added to the IV Med Drips section
    • Updated display text for CAPD fluid removed or retained
    • Care Assistant tab HED changes
    • VUH ICUS: ADULT Respiratory Care will begin documenting ventilator data in HED starting July 22
  • VUH/VCH
    • Med List Tool (MLT) will be embedded in provider H&P forms
    • IV drip medications  added to the IV Med Drips section
    • Updated display text for CAPD fluid removed or retained
    • Care Assistant tab changes

June 3, 2014

  • All VUMC
    • For all VUMC - There is a new link which will take the user to the Eskind Library
  • NICU and NBN
    • NICU and NBN have a new charting field of “Safe Sleep”.
  • VCH
    • Education Record > Education/Engagement Assessment >Cardiac Education – two new options
    • New charting field of GI Education with one option of “G-tube”
    • Added one option of "tracheostomy" to Pulmonary Education
    • Care Assistant Tab has the Notification section added to the top.
    • And, Incent Spiromtr and Resp. Interventn has been added to the Act Daily Living section
    • The Pulmonary/Respiratory Intervention charting fields have been standardized throughout VPH, Med/Surg, ICU’s, and Peds.  If charting field is not seen, users may have to hit show all
  • VUH
    • VUH > Nutr by Nursing > Patient’s Diet > Added Transplant Diet
    • Education Record > Education/Engagement Assessment >Cardiac Education – two new options
    • New charting field of GI Education with one option of “G-tube”
    • Added on option of "tracheostomy" to PUlmonary Education
    • The Pulmonary/Respiratory Intervention charting fields have been standardized throughout VPH, Med/Surg, ICU’s, and Peds.  If charting field is not seen, users may have to hit show all
    • Care Assistant Tab has the Notification section added to the top.
    • And, Incent Spiromtr and Resp. Interventn has been added to the Act Daily Living section
    • For OB > the OB Frequent Assemnt/Interventn > Postpart Asmt – the Incision/Wound documentation is now available
  • VPH
    • The Pulmonary/Respiratory Intervention charting fields have been standardized throughout VPH, Med/Surg, ICU’s, and Peds.  If charting field is not seen, users may have to hit show all

May 13, 2014

  • VUH and VCH
    • New Care Assistant tab in HED
  • VUH and VCH
    • Non-invasive Ventilation changes
  • VUH and VCH
    •  Pain > Motor Block (Bromage) is now force display
    • A new link added to Medications under "Links" in HED on how to schedule "skipped or staggered" medications
    • Vitals I&O Flowsheet > Vital Signs > CPAP Mask will no longer be chartable.  Any old documentation will remain viewable
    • The Hemocult Testing and the Gastrocult Testing have been consolidated so that this documentation is shared across Peds and Adult
  • VUH and VCH except NICU/NBN
    • Pulmonary > Intervention: Replaced vapotherm with Highflow Nasal Cannula
  • VUH ICU/SD only
    • Assessment/Intervention>Pulmonar: If Artifical Arwy > AIRWAY TYPE - Added Nasopharyngeal tube (final field); removed T tube and replaced with T-piece

April 29, 2014

  • VUH and VCH
    • TB skin test documentation changes in HED
  • VUH and VCH
    • There will be a new section for documenting Artline.  The new charting fields will be in site management format.
  • VCH 5A and 5C only
    • Artline changes: Any previous charting on SG-PA Catheters and Artline Catheters will remain viewable, but will no longer be chartable. There will be a new section in the Peds Asmnt>Cardiovascular = IntraCardiac Catheter.
  • VCH NICU only
    • Artline changes: The UAC/PAL section will have its name changed to UAC.  There will be no changes to the UAC.

April 15, 2014

  • VUH only 
    • New Nestle product options in the dropdown lists for “Oral-Nutritional Support Product Name” and to “Tube Feeding Product Name”.
  • VCH only
    • Feeding Cal/oz. has an additional option of 19 Cal/oz. in dropdown list.

April 8, 2014


April 1, 2014

  • All VUMC
    • A newLink for the VUH Foley Dicontinuation Protocol under Renal/UR assessment
  • OB/Postpartum only
    • Nurses will chart Incision C-section and Closeure sections under Skin/Wound section in the Assessments/Interventions tab
  • 5th Floor VCH only
    • ACTIVITY/Musculoskeletal care category will also be available on the PCU Quick Assess tab

March 18, 2014

  • All VUMC
    • Pain tab now Pain/Sedation
    • New format for all Ostomy/Stoma documentation with trended data
    • PIV insertion: added Unknown to Number of Sticks drop down menu
      • Unsuccessful sticks should be documented under No IV Access

 


March 11, 2014

  • All VUMC
    • TB skin test changes
    • Pain Assessment, Cannot Self-Report Pain, Physiologic Cues:
      Added “Elevated ICP” to the drop-down list:
       

February 18, 2014


January 21, 2014

  • VUH, VCH
    • Skin/Wound assessment
    • Positioning care
    • Therapy beds
    • Moisture Control Care

January 14, 2014


January 7, 2014

  • VUH, VCH:
    • Skin/Wound changes
    • Education Record
  • VUH only:
    • Med/Surg, OB, ICU Assessment changes
    • 11NM changes in Medipac

December 10, 2013


 November 15, 3013


October 15, 2013

  • VCH: Falls Score (Graf-Pif)
    • VCH except NICU and Newborn Nursery: Fall Risk Safety
    • NICU/Newborn Nursery only: Fall Assessment

October 1, 2013

  • VUH, VCH, OB: StarPanel Nursing Admission History changes
    • Tobacco, influenza, and functional screening

September 4, 2013


August 27, 2013

  • All VUMC:  Admission History Indicator Status

August 20, 2013

  • 7S will also have charting access to NIPS.
  • NBN:  Newborn Nursery flowsheet - Routine Assessment - PIV assessment no longer chartable.
  • 5A & 5C:  PCCU Quick Assessment - Alarm Settings - Temperature High or Low Alarms now have the ability to chart to one decimal point.

August 13, 2013

  • VUMC / VUH & VCH (except NICU & NB):  Isolation Type now force display; cosign med drips & added options to Precaution/Isolation & to Falls Risk/Safety sections.
  • VCH: Same Precautions Type documentation fields as VUH.   Added "Baseline (annotate)" to the Problem Assessment

July 30, 2013

  • VUH & VCH:  Moved "Bleeding Risk" to Cardiac Priority Problem section.  Additions options to the Tissue Perfusion Priority Problem.  Care Organizer & HED Links: added & updated documents.
  • VCH except NICU & Newborn Nursery:  Moved "Bleeding Risk" to Cardiac Assessment (Problems). "Tissue Perfusion Assessment (Problem) moved above Skin.  Additions options to the Tissue Perfusion Priority (Problems).

July 16, 2013


June 25, 2013

  • Urgent updates to the HED Safety section used in VUH and VCH
  • VUMC:  Notified/Referred charting field; Notify/Critical Results & Safety Notication/Care Coordination section -  Added "Respiratory Therapy" to dropdown list.   Plan of Care/Discharge tab - has display name change for Problems to include the word "Priority"
  • VUH & VCH (except NICU & Newborn Nursery):  Assessment tab - Neur section - "Mental Status/LOC" will no longer be "chartable".  RASS/LOC will be used going forward.  Instructions for RASS Scoring will be available in the RASS Score hover and the TASS Refence link has been updated.

June 12, 2013

  • VUH and VPH:  PAIN-AD Scale will now auto-calculate
  • NICU and NBN:  The N-Pass, NIPS and NWI will now have auto-calculating scores. Newborn Nursery -  NIPS scale was re-built in order for the auto-calculation feature to work. Previous NIPS documentation will be viewable but no longer chartable.
  • ICUs:  ICU/SD Assessment/Intervention and Peds Assessment/Intervention tabs - Pulmonary - Added new field of "Extubation Details" with options for "Self extubation" or "Accidental extubation".

June 4, 2013

  • ALL VUMC - Links menu: Added KRAMES "Adults" & "Peds" Patient Education Resources
    All Assessment/Intervention tabs: Added "In and Out Cath" shared field.
  • VUH - Vitals I/O tab:  Added "Nutr by Nursing" secontion below I&O Summary.- share with assessment tab.
  • VUH & VCH - Education Record:  Added "Cardiac Medication Education".

May 21, 2013

  • Launch HEO/WIZ from HED will be rolled out to ALL departments - PowerPoint

May 14, 2013

  • NICU & Newborn Nursery  - "PC-PSV VG" added in NICU Airwary devices & "Bilight Mgmt" in Phototherapy additional options
  • ALL VUH "Blood Transfusion Cosign Result" changed &  added "PEP Therapy" in Pulm/Resp

May 7, 2013


April 30, 2013

  • Click here - For 7N-VUH and 5C-VCH: Piloting a short cut to get from HED to HEO/Wiz while maintaining patient  context.
  • Click here - For Adult ED & Peds ED:  Procedure on Unit /Consult at Bedside - Added "Obstetrics/Gynecology" .
  • Click here - For VUH & VCH:  Blood Transfusion tab - Added "All Lines" to tab.
  • Click here - For VUH, VPH, VCH except NICU: Assessment/Invention tabs - Add "Intouch bed w.isogell mattress"  to dropdown
  • Click here - For 10S, S64 & S74:  Neuro - "CAM assessment now Auto-Calculates".

April 23, 2013

  • Click here - For VUH & VCH (except NICU) - Assessment tab - Added "Laceration Repair"; Blood Transfusion tab - Added "O2 Sat%"
  • Click here - For EMER - Adult ED - Vitial Signs - Added "ETCO2"
  • Click here - Hold and Resume Orders Review Tools

April 16, 2013

  • Click here - For ALL Departments - Added new output for Vesicostomy
  • Click here - For VCH - Peds Fall Assessment - Added new option to the Medication usage dropdown

April 9, 2013

  • Click here - For ALL VUMC - Urinary catheter require "Inserted Date"
  • Click here - RASS Score changes
  • Click here - For VUH and VCH (except NICU and Newborn Nursery) - Assessment tabs - FALL RISK/SAFETY
  • Click here - For OB - PIV charting added below CIWA charting
  • Click here - For NICU - SQC charting is now available on the NICU Assessment tab
  • For VCH: PEWS DAS will be available for all Peds Acute Care Units

April 3, 2013

  • Flu screening is complete for this season.  The Flu screening questions have been removed from all nursing admission history form.  Only Pneumovac screening remains


April 2, 2013

  • Click here - For VUH and VCH (except NICU & Newborn Nursery) - New addition Ventilator type: "Home ventilator"
  • Click here -  For VCH (except NICU & Newborn Nursery) - Peds VSI&O; PCCU Quick Assessment & AdminRx - added new intake option
  • Click here - For 5A, 5C 7A & NICU - Donor Breask Milk has new charting option

March 19, 2013

  • Click here - ALL VUMC - Changes to Vitals I&O, CIWS & Plan of Care/Discharge Plan.
  • Click here - VUH & MCJCHV except VPH and NBN - Added option to output
  • Click here - VCH only - Changes to Peds Vitals I&O and Peds Assessment/Intervention

March 12, 2013

  • Click here - For Children's Hospital 5A, 5C & 7A - PCCU Quick Assessmennt document change

March 5, 2013

  • Click here - For ALL - Restraint document changes.  Education Record changes
  • Click here - For PCCU - PCCU Quick Assessment
  • Click here - For PEDS ED and PEDS Acute Care - New links for PEWS Resource
  • Click here - For OB

February 26, 2013

  • Click here - For ALL VUH - Changes to send message, Cardiovasular & Pulmonary assessment on MedSurg/Intervention tab
  • Click here - For VUH & VCH - Tube level documentation tips added to hover in I&O
  • Click here - For OB Triage - Fetal evaulation
  • Click here - Adult & Peds ED - Oral ETT added to airway type, additional head & neck assessment choices

February 20, 2013

  • Click here -  For ALL areas - Updates to Links...HED/AdminRx Training Resources
  • Click here - For CRC - The Adult Falls tab has been removed in HED
  • Click here - For VUH - CAM-ICU result will no longer allow copy

February 12, 2013

  • VPH will receive PICC and PIV charting on their VPH Assessment tab

  • Click here - All VUMC lexicomp
  • Click here - CRC/S31 priority problems and safety
  • Click here - 10N SAT documentation changes in HED
  • Click herePeds ED new field for Full Cardiac Monitor
  • Click here - Adult ED Modifications Documentation in HED

Janurary 29, 2013


December 14, 2012

  • Click here - New Flu Screening section on Admit History


December 11, 2012

  • Click here -  ALL VUMC critical results notify, safety additions

  • Click here - Nursing History Updates 12/7/12 (2)

  • Click here - VUH & VCH Flolan & Rass Score changes


December 4, 2012

  • Click here -  ALL VUMC except NICU - Fall Risk & Priority Problem changes

  • Click here -  VUH add sutures to procedure options


November 27, 2012


November 13, 2012

  • Click here  - VUMC - CIWA enhancements- changes to pain location- IV med drips- safety changes
  • Click here - VCH except NICU - formula addition

 October 30, 2012

  • Click here  - For All VUMC - Plan of Care/Discharge Plan Tab 
  • Click here For VUH and VCH Assessment tab:  NEURO;  IV Other;  Vitals I&O or QuickAssess.
  • Click hereVUH only
    • Assessment tab: Special Neuro - new charting fields for Neuro Deficits and Stroke
    • New Safety Documentation:  Non-Implemented units and Implemented unit changes

    • Education Record: Role Communication- Interpreter Name change


October 16, 2012

  • Click here - Regular updates to HED documentation with screenshots
  • Click here - Heparin Drip education specific for 5 South and 6 South pilot, but visibe to everyone
  • Click here - Safety and Eduction roll out screenshots
  • Click Here - Notify Section Changes

October 9, 2012

  • Click here 
    • ALL VUMC:  Pain > Pain Interventions > Added “nerve block
    • VUH & VCH:  Intakes > Added “TPN with Lipids”
  • Click here -
  • VCH > 5A and 5C: PCCU Quick Asmnt > PCCU Quick Assmnt  &  Peds Asmnt/Intervention  > Cardiovascular - Added new Alarm Settings options
  • PCCU Quick Asmnt > VENTILATOR > added multiple new fields 

 October 2, 2012

  • Click here - For VUH and VCH except NICU and NN: Assemnt >Neuro>The Glasgow Coma Scale and Pediatric Glascow Coma Scale
    • For ALL VUMC: PAIN > Pain Interventions> ‘MD notified removed replaced with ‘MD/NP notified’
    • For 11NM, 6A, 6B, and 8S: AdminRx>Infusion Status ‘Rate Increase’ and ‘Rate Decrease’ added to the dropdown

September 24, 2012

  • Click here - Influenza Screening returns to the Adult, OB and VPH Nursing Admission history.
  • Click here - HED AdminRx has been updated with 2 new results for Influenza and Pneumovax vaccine administrations

September 18 & 24, 2012

  • Click here - For 5A,, 5C and 11S - Peds Asmnt/Interventn > CARDIOVASCULAR > SG-PA Catheter.  New charting fields of RA waveform and LA waveform have been added
  • Click here - Immunization screening update for September 24, 2012.  Please print, post, and share with all HED users in your area

September 4, 2012

  • Click here - For ALL VUMC - ASMNT tabs> CVC trended data> Gauge/Length - addition of 19g x 1 ¼
    • For 11NM, 8S, 6A, and 6B - Precautn/Isoltn section has been added to the Chemotherapy/Infusion tab


August 28, 2012 

  • Click here - APPLIES TO ALL 3 HOSPITALS!
    • Changed "Removed By:" to a text fill-in & "Removal Order By:" to a dropdown
    • Added "very dry" and "peeling" to Skin Condition dropdown
    • Added Argatroban to the Antiocoagulant Education dropdown
    • For ALL VUMC - ASSMNT and Pain tab > Pain Self-Report>Pain Scale-PAINAD scale added to dropdown options

August 21, 2012

  • Click here -  ALL VUMC - HED changes for 8.21.12  &  For ALL VUMC except NICU and Newborn Nursery & for OB 

August 14, 2012 

  • Click here - For All VUMC >Pain>Pain Site &  For ALL VUMC>Pain>Cannot Self-Report Pain>Physiologic Cues  

  • Click here -  For VCH to include Peds ED & Peds ED


August 7, 2012

  • Click here - On the OB Triage tab:Update to the Domestic Violence screen to match the Nursing Admission history;  & For CVICU:On the IV Med Drips class: Added Bivalirudin/Angiomax

 July 31, 2012

  • Click here --  OB and VCH changes as well as new Safety/Falls risk changes

July 17, 2012

  • Click here for "Upgrades to Inpt. Nursing Documentation Tools in HED and StarPanel Admission History coming Tue., July 17, 2012

July 11, 2012

  • Click here for "Change to Immunization Screen on Admission History" forms used with ADULT Inpatients was made today, Wed., July 11.


July 2, 2012 and July 9, 2012

  • Click here for Advance Directive (Purple form) in Starpanel & Vancomycin Advisor in HEO/Wiz

June 19, 2012

  • Click here for updates in HED effective 6/29/12
    • Increase in font size on all tabs
    • New Vancomycin Advisor on 7/9/12

April 17, 2012


 

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