CS-Link Update for All Inpatient Nurses and CCST

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Elwin Melton
8 years ago
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1 CS-Link Update for All Inpatient Nurses and CCST Tuesday, July 29th, 2014 On Tuesday, July29th, 2014 several improvements will be added to CS- Link. This document highlights the key improvements providers will benefit from and experience when these additions are made. To review each improvement individually use the hyperlinks below or visit the System Improvements page on to view all previous CS- Link Updates. DATA REVIEW Antibody Tests and Isolation Precautions FYI Changes to CS-Link

This document highlights the key improvements providers will benefit from and experience when these additions are made.

2 DATA REVIEW Antibody Tests and Isolation Precautions Highlights Occupational Safety and Health Administration (OSHA) requires hospitals to isolate patients identified with contagious diseases or pending a result from the lab to minimize the likelihood for exposure to blood or body fluids. Details Physicians will now see the isolation order clubbed with the antibody tests. Now, there is a way in CS- Link to identify and alert providers as soon as the antibody tests are ordered for the patients. Nursing will receive an alert as soon as the patient chart is opened and it will prompt them to page and notify Nurse Epidemiologist to take early isolation precaution. Nursing will also have this notification as a task list item on their worklist. Antibody Tests Now included with Isolation Order

Now, there is a way in CS- Link to identify and alert providers as soon as the antibody tests are ordered for the patients.

3 This improvement will Minimize any missed opportunities in preventing spread of infection on the floor. Meets the OSHA requirements.

4 FYI Changes to CS-Link Worklist Worklist Update: The Pneumococcal and Influenza Vaccine will now populate the nursing worklist. Note: The task will continue to populate the worklist every 12 hours until the vaccine is given. Removing the task from the Worklist: Notice that the button will appear grayed- out. In order to remove the task from the worklist, simply document the administration of the vaccine in the MAR and the task will automoatically disappear from the worklist. If you click on the vaccine. icon to the right, you will be sent to the MAR where you can administer the Adult VS/Hemodyn Report The Adult ICU VS/Hemodyn report will now be available in the Patient Summary activity to LDR/MFCU, Post- Partum, and Peds PICU departments

In order to remove the task from the worklist, simply document the administration of the vaccine in the MAR and the task will automoatically disappear from the worklist.

5 Braden Scale BPA The Braden Scale BPA was updated to reflect the Pressure Ulcer Policy stating a Braden Score of less than or equal to 18 puts the patient at risk for developing a pressure ulcer. Currently this BPA fires only for a braden score of less than 18. Default Medication Patch/Device on Head to Toe Doc Flowsheet Medication Patches and Devices have been missed during admission, shift change, assessments & transfer. Defaulting Medication Patch/Device Present in the Head to Toe doc flowsheet Skin Integrity section for all ages except NICU is intended to encourage a more thorough skin assessment, review of PTA medications, and dialogue with patient regarding possible presence of device or patch.

Default Medication Patch/Device on Head to Toe Doc Flowsheet Medication Patches and Devices have been missed during admission, shift change, assessments & transfer.

6 LDA Peripheral Nerve Line Peripheral Nerve Line LDA Location options have been updated to reflect current placement for improved LDA documentation The Peripheral Nerve Catheter medication infusion rows will now populate the Pain Assessment and IV MAR flowsheet rows for Peripheral Nerve Medication infusion documentation.

Peripheral Nerve Catheter medication infusion rows will now populate the Pain

7 Advance Directives The same Advance Directive documentation rows will be used across the organization. This allows for the sharing of information and will eliminate asking patients the same questions multiple times. An additional change to the type of directive row will now allow multi- selection instead of single select, because a person could potentially have all 3 types of directives.

This allows for the sharing of information and will eliminate asking patients the same questions

8 Pre- Procedure Checklist In the pre- procedure checklist, Eye Specialty H&P will now be Specialty H&P with a choice of Eye H&P or Podiatry H&P where the limited H&P by the specialist is required along with the Full H&P done by the Primary Physician. Specialty H&P cascading groups

Podiatry H&P where the limited H&P by the specialist is required

9 CP Vitals Flowsheet House wide the CP Vitals flowsheet will have the addition of Scale ID number row where they can document the ID number of the scale used when weighing the patients. For all RN/CP flowsheets that use the weight scale used row the drop down choices will now include infant scale and bed changed. The drop down choices have been modified to multiple section to allow for the choice of Bed Changed whenever the patient s scale bed may have been changed since the last time the patient was weighted to account for possible weight fluctuations NICU Documentation NICU flowsheet documentation changes going through to allow communication of all data collected on admission to populate in the NICU Head to Toe and Vital Sign Flowsheet. Where Pain documentation occurs the NIPS pain scale was added to allow the choice of the NIPS or PIPP pain scale. In the NICU Admission Navigator, the Admission Assessment was combined into one flowsheet and will now only be a link to that doc flowsheet instead of full documentation being done in the Navigator. LDA Negative Pressure Negative Pressure LDA: Target Pressure now includes selection 25 mmhg

The drop down choices have been modified to multiple section to allow for the choice of Bed Changed whenever the patient s scale bed may have been changed since the last time the patient was weighted

10 Wound Documentation Row information regarding partial thickness and full thickness has been added under the wound groupà Non- Staged Wounds row and Negative Pressureà Wound type row. Wounds: Non- Staged Wounds Negative Pressure Dressing: Wound Type Stroke- IR Documentation Flowsheet 'Time to Revascularization' and 'TICI post- treatment reperfusion grade' are now available in the Stroke- IR doc flowsheet. This documentation will satisfy Joint Commission requirements.

Wounds: Non- Staged Wounds Negative Pressure Dressing: Wound Type Stroke- IR Documentation Flowsheet 'Time to

11 SmartLists A SmartList is a drop down menu with customized options which appears as the user presses F2 to click through their SmartPhrase. All members of CCST can now create and maintain their own SmartLists. They will be able to insert their SmartLists into their SmartPhrases. Benefit: This will help streamline the process of writing concise and focused clinical notes. Please see the Job Aide on CS- Link Central for more details: JAMD0054 (Create and Maintain SmartLists) OT Assessment Notes Templates for standardized assessment notes and weekly progress notes were updated for occupational therapists in inpatient rehabilitation. Functional Electrical Stimulation Flow sheet rows for Functional Electrical Stimulation were created and/or updated for physical therapists and occupational therapists in inpatient rehabilitation.

Benefit: This will help streamline the process of writing concise and focused clinical notes.

12 RT Communication Order Several Inhalers will now include a RT communication order to be administered with a spacer (Fluticasone, Albuterol, Atrovent) Palliative Care Services Change to Palliative Care service Now called Supportive Care Medicine in Notes Activity and Chart Review SmartLink New Smartlink available for in- process Labs LDA Surgical Incision OR nurses can now create a Surgical Incision LDA intra- operatively where any receiving nurse will be able to see the LDA documentation and continue the LDA documentation.

Activity and Chart Review SmartLink New Smartlink available for in- process Labs LDA Surgical Incision OR nurses can now create a

13 Allergy Documentation Required (Stop- Sign) or Recommended (Yield- Sign) warnings will no longer appear in the severity field for allergies. This change applies to all users. Extracorporeal Life Support (ECMO) The perfusionists will now be documenting the ECMO machine values within CS- Link. Nursing will be able to view this documentation within DocFlowsheets

Extracorporeal Life Support (ECMO) The perfusionists will now be documenting the ECMO

14 Department Directory New Department Directory button will be inserted under the Web Activities button on the toolbar for IP nurses and ancillaries users.

Inpatient Cerner Navigation and Documentation For Nursing Students

Inpatient Cerner Navigation and Documentation For Nursing Students Audience Note: Purpose: Objectives: Cerner PowerChart training is for all students in the following inpatient areas Med/Surg, OSNO, Oncology,