Introduction to Incident Command Systems

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Volume 1, Issue 1 January, 2008
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RNs, LPNs, and Assistive Personnel. Please
review this booklet and complete the quiz.
Return your completed quiz to your manager by
January 30, 2007. If you have any questions
about the content, please contact your manager or
Kris Allen (5667), Lori Campbell (5449), Sue
Vollmar(5385), Sarah Lator(4284).

• Introduction

Nursing documentation is being changed based on
nursing feedback and following regulatory
standards. It will decrease forms, paperwork and
documentation for the Nursing staff. In turn
this will create more time for the Nursing staff
to be at the bedside. This will also improve the
nursing process and multidisciplinary
communication. The new process will link the AAR,
24-hour assessment, care plan and
interdisciplinary patient education record.
Streamlining the process will allow for better
documentation for your patients, care plans that
are specific to your patients and improve patient
outcomes. For further questions regarding the
different forms, please refer to the guidelines
in the Nursing Policy and Procedure Manual.
Coming Soon New tabs for documentation
placement. Signature record, 24-hour assessment,
AAR/care plan, flow sheets (wound flow sheet
neuro/neurovascular) and critical
pathway. IMPORTANT All documentation forms must
to be kept in the patients chart at all times.
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Nursing Process

• Nursing Process
• The Nursing Process is based on a nursing theory
  developed by Ida Jean Orlando. From her
  observations she learned
• The patient must be the central character
• Nursing care needs to be directed at improving
  outcomes for the patient not about nursing goals
• The nursing process is an essential part of the
  nursing care plan
• The nursing process consists of basically
  five steps. All nursing personnel take part in
  the nursing process however, the RN has the
  primary responsibility.
• The Five Steps
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation
• Assessment
• This is the data collection step. The
  collection of data is recorded on the AAR, 24
  hour nursing flow sheet and the education record.
• Diagnosis

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Nursing Process (continued)

• Planning
• Setting goals to improve the outcomes for
  the patient are a primary focus of the nursing
  process. The care plans are numbered by systems
  by which they correspond. These numbers are
  consistent throughout the AAR, 24 hour record,
  and the care plans allowing for quick reference.
• Implementation
• Setting your plans in motion and delegating
  responsibilities for each step. All members of
  the healthcare team should be responsible to
  report back to the RN all significant findings
  and to document their observations and
  interventions as well as the patients response
  and outcomes on the 24 hour patient record.
• Evaluation
• The nursing process is an ongoing event.
  The evaluation incorporates all input from the
  entire health care team, including the patient.
• The Whole Patient
• The nursing process involves looking at the
  whole patient at all times. The process provides
  a road map that ensures good nursing care and
  improves patient outcomes.

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Changes in the Documentation

• Revised forms 72-hr Patient Assessment Record,
  Adult Admission Record, Care Plans.
• Deleted forms that are now included in the 24-hr
  patient assessment record Intake Output,
  Hourly Graphic Sheet and Blood Glucose form. The
  nursing notes form has been deleted as well.
• Deleted DAP format You only need to chart
  changes in the patients condition on the 24-hr
  assessment. Document major problems, calling
  doctors (patients K 2.5 and what you did for
  the patient and the outcome), abnormal labs etc.
  on the patient progress note. Start by writing
  Nursing and put related care plan number by
  it. Keep it short and to the point.
• Use the Interdisciplinary Patient Education
  Record to document all patient/family teaching.

NEW FORMS Signature Record And 24-hr
Patient Assessment Record
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AAR Adult Admission Record Changes

• Page 1
• Deleted Medication and Allergies section
• - this information is now on the
  Medication Reconciliation form.
• Added Section E for things that must be reviewed
  and completed upon admission. Reminders (PIN ,
  Advanced Directives, Medication Reconciliation
  form, Smoking Cessation info., Vaccines, and
  Medicare Discharge Rights.)
• Added Care Plan s to all areas of assessment.
• Page 4
• Expanded the Substance Use section Q and added
  the CAGE questions.
• Added a Psychiatry section R with a Care plan .
• Page 5
• Delete the Wound flow sheet. If wound is
  present, you must complete the Wound Flow Sheet
  670-33.

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24-Hour Patient Assessment Record

• Replaces the 72 hour assessment record.
• Added the Hourly Graphics, IO, and Glucose
  Monitoring information to this form so these
  forms are deleted.
• All key information has been moved from the
  bottom of the form to after each section.
• Deleted the DAPing format. Use the lines next to
  the body systems to chart abnormals/procedures.
  Chart in the Patient/Physician progress note for
  major problems.
• Care plan numbers have been added to this form to
  link problems to the AAR and care plans.
• Pain assessment you must reassess your patient
  after pain medication is given. Use the pain
  protocol in the key to document correctly.
• Basic care section- Hourly rounds and turning
  positions have been added. The RN or assistant
  must check on their patients hourly and check the
  3 Ps(pain, position, and potty), and then sign
  your initials.

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Charting by Exception

• 1 Everyone will document using charting by
  exception each shift.
• Assessment, ADL, and treatment data is recorded
  at least once per shift on the 24-hour
  assessment.
• When assessment findings, interventions/procedures
  need further documentation, write a short
  narrative in the nurses note section of the
  24-hour assessment next to the assessment column.
• If further space is needed for items of major
  importance, document necessary information (using
  the narrative format) in the Patients Progress
  Notes.
• Examples of Charting by Exception
• Lab called you with a critical value of K
  2.5. Document in patient progress note the
  finding and your follow up. In progress notes
  writeNursing-11/27, 0800, critical value K 2.5
  called by lab, Dr. Ghose notified of lab results
  see orders. No need to document further if
  orders are given, the written order will document
  the follow up plan. Assistive personnel should
  not be documenting on the patients progress
  note. They should document procedures in the
  nurses note section. Examples Inserted 16fr. F
  (FFoley)- tolerated well. Write urine amount in
  I O section.
• Use the Interdisciplinary Patient Education
  Record for all
• education taught to the patient and
  family.

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Care Plans

• Goal Allow for the use of the nursing process
  in the
• development of patient care plans.
• Focus Streamlining the process to allow for an
  effective care plan which is specific to your
  patient, quick to develop and quick to review.
  Each care plan is numbered 1-14, which
  corresponds with the area of assessment. These
  numbers are consistent throughout the AAR, 24
  Hour Assessment and the Care Plans allowing for
  quick reference between multiple tools. Nursing
  can maintain a complete plan using assessment
  information gathered from admission to present.
  Care plans are to be reviewed each shift. Care
  plans only need to be printed upon initial
  development and when revised.
• Key points
• - Created upon admission based upon admission
  assessment.
• - Printed when developed
• - Reviewed based on patient assessment each
  shift as well as any transfer of care.
• - If no revisions/additions needed mark care
  plan and reviewed on 24 hour assessment
• - If revisions needed mark are plan and
  revised on the 24 hour assessment. Print revised
• copy for the chart.
• New Care Plans
• 1. Pain Altered Comfort
  8. Substance Abuse
• 2. Safety
  9. Psychosocial
• 3. Neurologic/Neurovascular 10.
  Endocrine
• 4. Cardiovascular/Peripherovascular 11.
  Oncology
• 5. Respiratory
  12. Nutrition Altered
• 6. Gastrointestional (GI/GU)
  13. Knowledge Deficit

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Signature Record

• Sign the signature record if you are documenting
  on any part of the patients (inpatient/outpatient
  chart)
• Sign once per hospitalization.
• Use your legal signature Full first name, middle
  initial, and last name.
• Write in your 3 initials (if you have 3)
• Write in your classification.
• Print your full name.
• When documenting on any form in the patients
  chart, sign with 3 initials (if you have 3)

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Final Exam
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Final Exam 1

• 1. Care plans need to be printed every day.
• True
• False

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INCORRECT
Care plans only need to be printed upon initial
development and when revised.
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Final Exam 2

• 2. Document all patient teaching on the
  interdisciplinary education record.
• True
• False

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INCORRECT
Use the Interdisciplinary Patient Education
Record to document all patient/family teaching.
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Final Exam 3

• 3. Assistive personnel will document ADLs
• and treatments on the 24 assessment
• and not the patients progress notes.
• True
• False

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INCORRECT
Assistive personnel should only document
procedures and ADLs in the nurses note section.
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Final Exam 4

• 4.  The 24 Assessment will remain
• in the patients chart under the
• 24 Assessment tab.
• 
  
• True
• False

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INCORRECT
The new tabs for documentation placement include
Signature Record, 24-Hour Assessment, AAR/Care
Plan, Flow Sheets, and Critical Pathways.
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Final Exam 5

• 5.      Nursing care is directed at improving
• patient outcomes.
• True
• False

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INCORRECT
Nursing care needs to be directed at improving
outcomes for the patient not about nursing
goals.
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Final Exam 6

• 6. Nurses will chart critical data in the
• patients progress notes.
• True
• False

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INCORRECT
If further space is needed for items of major
importance or critical data, document necessary
information using the narrative format in the
Patients Progress Notes.
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Final Exam 7

• 7. Hourly Rounding is evidence based
• practice that is documented on the
• 24 Assessment and addresses position.
• True
• False

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INCORRECT
Hourly rounds and turning positions have been
added. The RN or Assistant must check on their
patients hourly and check the 3 Ps (Pain,
Position, Potty).
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Final Exam 8

• 8. Hourly Rounding is optional for
• patients who are not q2 hour turns.
• True
• False

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INCORRECT
Hourly rounding is required for all patients.
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Final Exam 9 (last ?)

• 9. When assessing patient pain you dont
  have to recheck with the patient after an
• intervention
• A. True
• B. False

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INCORRECT
You must reassess your patient after pain
medication is given using the pain protocol in
the key to document correctly.
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You have successfully completed the Nursing
Documentation exam!!! ?
CONGRATULATIONS!!
Certificate of Completion - Click Here