1. Inpatient Nursing Documentation Changes During COVID-19
In an effort to assist staff and ease the burden of documentation, Nursing will be adapting the following streamlined disaster documentation in the Med/Surg and Critical Care areas starting today. Rounding will occur on the units and team huddles will be conducted. Documentation should be completed in the Disaster Admission Navigator.
Here are the key highlights:
- Use of a new Disaster Admission Navigator with decreased admission documentation for all patients in Adult Med/Surg and ICU areas
- Current navigators will remain accessible and are available if an RN would like to document more than required
- Required documentation for Falls Score and Braden Scale has been changed from every shift to every 24 hours
- Removal of BPA logic that adds Care Plans
- Removal of automatic addition of First Dose Education for medications
- Care Plan and Education will be replaced by SmartText in RN Shift Note
New Disaster Admission Navigator
Waiving the Requirement to Develop a Care Plan for Each Patient
During the crisis, the use of Care Plans is not necessary. Since the education activity includes information added by the creation of a care plan, nurses will no longer be required to document in the Education activity. To support this change:
- All Best Practice Advisories (BPA) that recommend a Care Plan Template based on documentation or orders will be turned off
- Nurses will no longer document Care Plan Notes in the Care Plan section
- The RN Admit Note contains text for documenting that you have discussed a Plan of Care and Educated the patient
* The plan section of the note includes the specific plan for the patient
- Nurses will document a Nursing Note at the end of each shift
- At discharge, skip the Care Plan and Education sections of the navigator
Nursing Note - Med/Surg & Critical Care
The new Nursing Note will include the following statements:
- The plan for the day was reviewed with the multidisciplinary team.
- The plan and patient education was provided verbally to the patient and/or family during the shift.
- Patient and/or family were accepting of this information and verbalized understanding.
- Any additional details and/or outstanding concerns are listed below.
Restraint documentation is embedded in the Shift Note. If there are no restraints, delete this section:
If your patient is in Med/Surg and on telemetry, you do not need to write a separate note about telemetry. If appropriate, you can add information to your Nursing Note. You should still document on the strip and place it in the chart.
If the patient falls, use the
IP RN Falls Event Note SmartText in your note.
For more information and step-by-step instructions, click here.
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