Nursing Preceptor Training Guidelines

Transcription

1 Nursing Preceptor Training Guidelines Modules to complete 1 Help/Resources 2 PAL Patient Lists for RN/LPNs 3 PowerChart Overview for RN/LPNs 4 Nursing Documentation for RN/LPNs 5 emar 6 Labs 7 Orders 8 Tasks 9 Patient Hand Offs 10 Suspending Orders 1 Help/Resources a Identify superusers for your nursing unit b Identify correct order/steps to follow when needing information/help i If the equipment is not working? (1) Check to see if it is plugged in and on (2) Ask other staff for assistance (3) Call ii If your log in is not working? (1) Call iii If you are having powerchart problems? (1) Ask your superuser or other staff for assistance. (2) Refer to the training manuals on the unit and MCGHI website (3) Page Clinical Informatics c Locate patient care electronic medical record (EMR) resources on website/unit i Individual should go to hospital web page available resources and unit based manuals and identify following items: (1) Locate Policy/Procedure: corporate, patient care (2) General nursing skills manuals (3) Patient education: General education and Lexi-Comp-point out can be in different languagescan print from this area (4) Pathology Manual with test names and synonyms (5) PSN Variance Report Entry (6) Identify appropriate downtime procedures/resources (a) Locate downtime information (i) Downtime resource book on the unit (ii) MCGHI website downtime information (iii)powerchart Nursing Downtime Procedure (7) Locate patient care EMR resources on website and unit (a) Website under Patient Care/Nursing Documentation (i) Locate training manuals on MCGHI website (b) Locate resource manuals on unit ii Verbalize to send non-urgent questions to [email protected] 2 PAL/ Patient Lists for RN/LPNs a Create location and custom patient lists i Build a location list ii Build a custom list iii Place patients on the custom list from the location list (1) Delete patients from the custom list (2) Explain why it is important to start from a blank custom list each day

2 (a) Custom lists do not update if a patient went home and was readmitted (b) Ensures the proper encounter is selected for the patient iv Place custom list on PAL v When to change to location list on PAL (1) Working in a small nursing unit (2) When you are the charge nurse and need to view all patients b Identify why and when to alter patient list and timeframe of PAL i When working in another area of the hospital or during a different shift c Identify the purpose/function of the PAL column i Patient Name ii Demographics identify location, attending, service, etc iii Notifications alerts the user that new orders, new results or sticky notes exist on the patient (1) Orders or Result Notification Icon clipboard (a) Emergent/ Urgent Pharmacy Order Icon red exclamation mark on clipboard or next to eyeglasses displays in the Orders column not in the order notification window nor the nurse review window (b) Critical Result Icon red checkmark on the clipboard and red exclamation mark next to clipboard in the Lab or Rad column signifies a critical result (c) Orders Notification window (window which opens after clicking on the clipboard) Contains list of orders to note since last notification was applied by the user (i) Check each order for things the nurse is responsible for so they will know what type of tasks they must perform. (ii) Red text denotes emergent pharmacy orders (iii)click apply (iv) If nurse review icon precedes order, a nurse still has to perform the nurse review/sign off the order (v) Click X in upper right corner to close notification window (2) Orders Requiring Nurse Review Icon eyeglasses (a) Denotes an order which has not been reviewed by a nurse (3) Note Icon notepad with a pushpin (a) Used to communicate information that is relevant but should not be a permanent part of the medical record d Perform Nurse Review on orders i Open the nurse review window, choose review button at bottom. ii Uncheck the select all before reviewing. iii Places check in each order as they are reviewed iv Applies and signs the review. e Tasks Icons and columns identify outstanding tasks and assist in workflow (1) Columns (a) Overdue displays all nursing tasks overdue > 1hr and nurse collect tasks overdue > 2hr (b) PRN/Continuous displays all active PRN and/or continuous tasks (c) Current displays all pending and In Process tasks due during the time frame of the PAL (d) Hourly time column (i) Displays all pending and overdue tasks whose scheduled time falls within the specific hour column (ii) The column will not disappear until the task is completed or the time frame for the PAL is changed (2) Icons (a) Heart nursing tasks (b) Lungs respiratory therapy/nursing shared tasks (c) Chair patient activity tasks (d) Blood Drop specimen collection tasks

3 (e) Yellow Scribble and Clock co-signature required ii Results Weights and any other individually defined specific result (1) Defaulted columns (a) Actual Weight nurse entered weights (b) Dosing Weight- MD entered weights (i) Weight based medications should be dosed based on the Dosing Weight (2) Customize features of PAL columns as a training item--add Capillary Blood Glucose column 3 PowerChart Overview for RN/LPNs a Be able to identify the information found in the tabs this will be (1) under each tab description below b Be able to identify where information in the tabs comes from this will be (2) under each tab description below c Be able to navigate through the chart i Task List (1) Individual tasks needing to be completed by providers (2) From orders ii Allergies (1) List of all documented allergies (2) From pharmacy, MD and nursing staff documentation iii Clinical Flowsheets (1) Patient assessment information (2) From nursing staff and ancillary documentation iv Clinical Notes (1) The complete official electronic medical record except for MAR and Intake and Output (2) From forms documented by nursing staff and ancillaries, nursing and physician notes, and HIMS scanned documents v Form Browser (1) All forms which are in any state of completion (2) From forms documented by nursing staff and ancillaries vi ICU Summary (1) Selected pieces of information from the patient electronic medical record---information has nothing to do with an ICU stay or ICU specific information (2) From nursing and respiratory documentation, lab and radiology results, IDX registration information, and clinic visit information vii Intake and Output (1) All electronically documented intake and output information (2) From nursing staff direct charting and MAR fluid administration documentation viii Lab results (1) All laboratory and POC lab results (2) From lab technician entries and nursing point of care documentation ix MAR (1) Medication lists with tasks for administration (2) From orders x MAR Summary (1) View only list of all medications ordered, administered or due for this encounter (2) From Orders and MAR documentation xi Medication List (1) List of all medications from this inpatient encounter and all the historic and outpatient prescription medications regardless of encounter (2) From orders and clinic documentation xii Medication Profile (1) List of all medications past or present home or hospital regardless of encounter

4 (2) From orders and clinic documentation xiii Patient Care Summary (1) Quick synopsis of the patient chart similar to the paper Kardex (2) From information on other tabs xiv Patient Information (1) Patient Demographics (a) Patient address, etc. (b) From patient registrations, (2) Visit List (a) List of all past, present and future hospital and clinic visits at MCG (b) From patient registrations (3) PPR Summary (a) List of every provider who is associated with the patient (b) From providers entering the chart (4) Problem List (a) List of documented patient problems (b) From MD documentation (5) Immunizations (a) List of all documented immunizations for the patient (b) From MAR and nursing staff documentation xv PowerOrders (1) List of all orders from this encounter (2) From physician entry xvi Precautions (1) Information needed by any area who will come in contact with the patient, such as pregnancy status, fall risk, etc (2) From nursing staff documentation xvii Radiology Results (1) Results for the patient which has been entered through the radiology system (2) From radiology technician and radiologist entries xviii Respiratory Flowsheet (1) Patient assessment information (2) From nursing staff and respiratory documentation xix Vital Signs (1) Vital signs, height and weight information (2) From nursing staff documentation 4 Nursing Documentation for RN/LPNs a Navigate through AdHoc folders i Open the AdHoc folder and find a form to chart on ii Understand when it is appropriate to use Ad Hoc folder (1) Unscheduled patient care activity (2) No task on Scheduled, PRN or continuous task list for the needed charting b Understand correct completion requirements for Powerforms i Identify all sections in a form should be completed prior to signing the form ii Identify the required fields which turn from yellow to white when complete iii Identify the X which changes to a blue check when a section has all the required fields filled out iv Single or multiple answers possible (1) Round radial buttons are single responses (2) Square radial buttons allow multiple responses v Understand conditional fields and section (1) They only become available to chart in when a specific question response is chosen

5 (2) Some fields will only accept specific range of numbers such as temperature not being able to exceed 48.8C vi Comment (1) Any question can have a comment added. (2) You must select some answer to add a comment vii LPN and Graduate Nurse assessments require a co-signature by RN viii Modify, Unchart and View previous documentation c Create/modify clinical note d Chart new data in the Intake and Output i Find hidden categories to chart a line item ii Chart a new volume iii Modify the volume iv Unchart the volume 5 emar a Document Scheduled Medication i Identify an overdue medication by Red task icon and clock to the left of timeframe bar b Document Non Scheduled Medication c Document PRN Medication i Identify the last time the PRN medication was given ii Complete the PRN Medication Response form d Document Continuous Infusion i Document (1) Begin Bag and Site (2) Infuse Volume (3) Bolus (4) Waste (5) Rate ii Documenting on discontinued medications and continuous infusions iii PCA/Epidural/Narcotic Infusions (1) Bag number for the start bag field should be the pharmacy control number (2) Chart shift volume at the end of every shift iv Nurse Witness v Co-Signature of Medication Administration vi Charting by Proxy e Emergent and Urgent Situations i How to order out of the medication OverRide folder f Modify EMAR documentation i Open and change a time of administration on a previously charted med ii Unchart a medication because it was in error g Protocol Orders i Only in ICU-all are electrolyte replacement orders ii When and How to order the electrolyte h Reschedule Medication times i Identify a med which has not been verified by pharmacy (1) NEVER reschedule all med times when in unverified state 6 Labs a ii Reschedule a single med task iii Reschedule all med tasks (a) Identify the icon which displays on a medication task which has a modification-reschedule of all med times are considered modifications Locate lab order/collection information i Pathology manual on home page

6 ii Collection label iii Task/Order b Properly label specimen i NO gel pens ii Legibly enter Cerner user name and accurate collection time/date c Communicate when appropriate for a nurse to order a lab and how to order labs i Specimen rejected by lab ii Demonstrate ordering a lab i.e. BMP for a hemolyzed specimen replacement 7 Orders a Filter, customize and sort orders tab i Change display to read All Orders (All Statuses) b Explain how to initiate PowerPlans i Obtain verbal order from physician and write in paper chart ii Initiate PowerPlan using verbal communication type iii If any alerts or missing details come up, refresh the screen because you cannot complete the initiation process. c Order override meds Order Lorazepam 1mg IV d Access reference material right click on the potassium protocol on the MAR 8 Tasks a Complete ordered actions from Scheduled Patient Care Task List i Perform Vital Signs task ii Chart done to Intake and Output b Complete an ordered actions from All PRN Task List c Complete an ordered actions from All Continuous Task List d Complete an ordered actions from Nurse Collect Task List i Locate the accession number for the task being done to match with a label e Demonstrate Rescheduling one time or all tasks i Reschedule of 1 task from task list ii Reschedule of all tasks from orders tab f When is it appropriate to reschedule vs chart not done i Chart not done if this particular task should never be done ie patient was off the floor during vital signs and did not return until near the next task time ii Reschedule the task if the task was appropriate but needed to be done at a later time g Task list colors and icons i Grey tasks cannot be charted on by the position logged in ii Alarm Clock in first column denotes overdue task iii Yellow in first column denotes a Done/Not Done task iv Grey in first column denotes task opening a Powerform to complete v Pencil In -Process (missing required field) taskvi Yellow Scribble and Clock Pending Validation task-you cannot perform any of these tasks vii Yellow with Green Checkmark Complete task viii Eyeglasses Order has not had a nurse review applied to it h Suspend Orders i When is it necessary to suspend a patient s orders (1) Transfer to another unit (2) Transfer to OR (3) Transfer to a major procedure (4) Refer to CPOE Orders Management Policy Appendix for details 9 Patient Hand Offs a Communicate information from PAL and Task List i Reconcile the overdue tasks and review upcoming care needs b Communicate information from MAR/MAR Summary

7 i Reconcile overdue tasks reason for etc. c Communicate information from Patient Care Summary d Perform Chart Check i Place the Chart Check Performed order with required fields filled in for the time period covered by the chart check ii Set up the orders tab ready to perform an electronic chart check (1) Customize view to add Last updated (2) Group orders by None (3) Sort orders by Last updated 10 Suspending Orders a When is it necessary to suspend a patient s orders (1) Transfer to another unit (2) Transfer to OR (3) Transfer to a major procedures (4) Refer to CPOE Orders Management Policy Appendix for details b Identify orders which should not be suspended c i Lab orders ii The orders which the system will not allow to be suspended (1) Once orders which are in the past (2) Completed/discontinues orders (3) Pending validation Demonstrate suspending all appropriate orders i Choose correct physician and communication type in communication window. ii Highlight orders to be suspended iii Choose suspend action iv Choose suspend reason v Sign vi Refresh the orders tab view and see the suspended order status of orders