Nursing Documentation

What's New in Nursing Documentation

October 6, 2015

  1. In the Medication order and the Confirm/History button in Care Organizer, there is a new option in dropdown to send pharmacy a message “PLEASE SEND NEW IV BAG/SYRINGE”

  1. Assessment tab>IV Other and on Hemodialysis >Access- Hemodialysis and on Apheresis > Access will now see one set of results for Dialysis Access

  1. Assessment tabs>Neuro section – Pediatric Glasgow Coma Scale will now be available to all pediatric units except NICU and NBN

  1. Added link to the Nutrition Care Manual available through the EBL site

September 1, 2015

    • Updates to Influenza screening for 2015-16 season
  • VCH
    • Flu shot elegibility status will generate an order

August 25, 2015

  • All VUMC
    • There will now be an place to chart “Present on Admission” in the One Time/New Wound section
    • There are now two option to locate PUP and PU Intervention Resources

    1. Directly under Skin Integrity
    2. Or under either the Adult Skin/Wound References or the Peds Skin/Wound References
    • For restraints> the dropdown list has changed.  The new options will be “initiated”, “continued”, or “discontinued”
    • FALL RISK/SAFETY>There is a new option in the Falls Risk section for “Pt Incapable of Moving”, as well as an option for “Low – pt incapable of Moving in the Fall Risk Precaution Status (Morse) dropdown list.
    • Assessment> Pain> the Adult ICU units will now have new tool for Critical Care Pain Obs Tool section
  • Newborn Nursery and NICU
    • CCHD Screening:  Added’ Echo completed’ to dropdown

July 28, 2015

July 7, 2015

  • HED changes for all VUMC
    • New Links are available for references for Lidocaine Infusion for pain management
    • Assessments>VAD added new fields for HeartMate III
  • Med List Tool (MLT)
    • New "Add" box
  • New Born Nursery
    • Audiology will be documenting the Hearing Screens. HED fields are "No charting allowed".

May 12, 2015

March 3, 2015

  • New Born Nursery
    • The Halo charting fields have been replaced with fields that are not brand name specific

February 17, 2015

January 27, 2015

  • L&D& 4E
    • Breastfeeding has been added to the dropdown list
  • All VUMC
    • A new link available which will take the user to EDOCS form for Pharmacy Medication Scanning Issue Report
  • VUH & VCH
    • Electronic IV Therapy Request Form tip sheet

January 20, 2015

  •  New Born Nursery

    • Additions to the Care Partner tab
  • NICU

    • Additions to the Care Parnter tab
  • VUH

    • BMI calculations
    • Menincoccal vaccine to flow into the immunization record

December 16, 2015

November 11, 2014

  • All VUMC
    • The following changes are mainly for the Infusion Clinics but will be seen by all HED users. The changes will go into effect Tuesday November 11, 2014.
    • Changes to Lumen Intervention drop-downs for CVC and PICC.

October 7, 2014

  • VUH only
    • EstDC column added to VUH inpatient whiteboards
  • 4NPL, 4EST, & 4MSC
    • Breast Feeding Support Education added to Postpartum Asmnt/Intervetn->Breast
  • All VUMC
    • Added to all Nursing Admission History forms to Tobacco Use Screening->Tobacco related products->E-cigarette
  • All VUMC
    • Added to all Nursing Admission History forms->Febrile Traveler Screening

September 16, 2014

  • NICU
    •  Addition to NICU VS I&O-> Transfer/Transport ->Post- Procedure Temp
    • Blood Transfusion tab
      • Cosign has changes to the display name
      • The hover over description has also been modified
      • Plasmanate is no longer chartable

August 26, 2014

    • Addition to the Intakes-> Oral nutrition supplement
  • VCH
    • Addition to the Intakes ->Formula/Supplement

August 5, 2014

    • 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
    • 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

    • 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
    • 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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