Consolo Nursing Documentation Guide

Transcription

1 Consolo Nursing Documentation Guide This focus guide will explain Consolo functionality for the Nursing Documentation interface. Steps for completing a Consolo Nursing Visit will be depicted in a series of screenshots provided below with explanations. In an effort to create a more acceptable charting environment for the non-registered Nurse user, the descriptor Assessment has been removed from most of the nursing documentation to allow non-rns to document observations within the new interface in accordance with their accepted levels of State Board of Nursing-mandated nursing practice. The Consolo Nursing Documentation is accessible under the Clinical Charting section from the Patient Homepage by clicking the + alongside Clinical Charting link on the homepage. The old Homepage link for Create an Initial Nursing Assessments has been removed go to Clinical Charting + to add all clinical documentation. Once the Clinical Charting page displays, the Nursing Documentation sections are now available in separate sections in the left-hand side sections index. Under Common Sections at the top of the page is found sections titled General Clinical Chart, Patient Time and Electronic Visit Verification). These 3 Common Sections will be automatically present on any Clinical Charting entry created. The General Clinical Chart will be the location for identifying the visit date, what your discipline is based on Role and where to identify who is completing this note. Related Links, now in the tab bar, will have a selection of tasks that can applied to this specific Clinical Chart note. 1 Page

2 General Clinical Chart Section Patient Time Section Patient time for the selected documentation events is set in each charting event. The Patient Time completed will apply to ALL documentation components for this Clinical Charting Note. 2 Page

3 Electronic Visit Verification Section The next optional section in the index is for electronic visit verification, if used by your agency. For more details, please see your office administrator. Clinicians will see selections of charting sections on the left-hand side of the screen in an index titled CLICK TO ADD SECTION. Each section that will be used to comprise the Clinical Charting entry is chosen by clicking and adding it to SELECTED SECTIONS. See figures below for demonstration: Page

4 3 It is now possible to create a Nursing Document that is customizable to the patient situation and the clinician s needs. Each area of assessment concern can be accessed and completed as appropriate for the type of nursing visit being accomplished and multiple sections such as Pain Observations, Nursing Pain History and Wound Assessments can be completed in one entry to address multiple primary sites: Any section can be added to Selected Sections multiple times as needed to provide specific site or Body System information on assessment/observation. CLINICIANS NOTE*** - If cloning, be advised that only the first Pain Observation/Wound Assessment entry data will clone. For multiple Pain/Wound entries, the primary/first entry can be cloned but not any of the following sites for other Pain/Wound entries, the clinician should View the previous documentation to review and add any previous assessment data themselves to the current Assessment as desired. This issue will be resolved in a future release. 4 Page

5 Note when scrolling down that the Patient Status bar will remain static at the top of the page so that it is always in view: If a section is added inadvertently or in error, disable that section as shown: Page

6 A key concept to understand a basic complete Nursing Assessment in the program is defined as a Vital Sign Measurement section and at least one of the Body System Finding section this is a definition and not a statement of practice policy. Completing a basic Nursing Assessment as described will serve to satisfy all Follow-Up Nursing Assessment Alerts on the Classic Dashboard. For example, there is an alert on the classic dashboard for a Fall Event requiring a Follow-Up Nursing Assessment. The nurse performing the follow-up clinical chart will be required to complete at least a Vital Sign Measurement section and at least one of the Body System Finding sections to constitute a completed Nursing Assessment and subsequently satisfying the dashboard alert. Any other sections can be added to the Clinical Charting event as desired; the minimum charting, though, must be the Vital Sign Measurement and at least one Body System Finding section. THE DOCUMENTATION SELECTIONS Users will note that once they choose their Nursing discipline, the Charting selections on the left will display as appropriate for that specific discipline according to permissions set in roles. This means, for licensed nurses, all Charting pertaining to the Nursing discipline will be available, along with any other areas your Hospice desires you to have access to. Other discipline documentation choices such as Social Services, Spiritual and Hospice Aide will not display in the Nursing documentation choice list unless permissions are set to allow the user to have access to them. As stated above, this means that this particular visit can be customized to contain only the specific areas of assessment desired by the clinician. Only the areas to be charted in are accessed and all completed areas of documentation are related by date in one customized and comprehensive Clinical Charting Note, rather than having to complete one large and static Nursing Visit Assessment document. All charting components are listed in alphabetical order in the charting choices index. A typical basic Admission Comprehensive Nursing Assessment can include the following components: - All Body Systems findings - Coordination of Care - Nursing Health History - Nursing Pain History - Nursing Related Observations - Nursing Summary - Vital Sign Measurement - Pain Observation Any other associated Mini-Assessments can be completed per clinician preference and decision; Morse Falls, Skin Integrity, and Teaching and Learning Assessment. Please remember in order for a Clinical Chart to be acknowledged by the program as a Nursing Visit (and display a Nursing Visit icon in Clinical Charting), the entry must contain the Vital Sign Measurement section plus at least one Body System Assessment. If using the Visit Note to represent a Nursing Visit, the Clinical Chart entry must have an RN, LPN/LVN, or Skilled Nurse Discipline in General Clinical Chart section and the Visit Note section must have an asterisked Visit Type selection made, such as Home* or Assisted Living*. 6 Page

7 Body Systems Sections After completing the Clinical Chart, Patient Time and Electronic Visit Verification sections, the next selections in the index will begin the Clinical Charting sections. These selections derive from the multiple Assessment tabs in the old version of the Consolo Nursing Assessment and are now available to be addressed separately by the user to be a part of the overall customized Clinical Charting Note. An important note Cloning (charting by exception) of previous notes to a current note for review of previous assessment/observation data will continue to be available for those agencies desiring to utilize this functionality the default setting is blank assessment. In each Clinical Charting-related section, there is a Clone button that will allow the user to copy over previous assessment/observation data from a previous note for display in the new note. The Clone feature is a permissions-controlled function; agencies not desiring this feature for clinician use can simply not check the Role permission for Cloning under Clinical Charting permissions in Roles. Not allowing cloning will mean clinicians will be creating a new blank clinical note each time. This button is shown below: See figure below for an explanation of the Cloning function in Consolo. Cloning Functionality: See the following for a description if using the Clone feature, also called charting by exception: Admit Visit 2 Visit 3 Admission Nursing Assessment Nursing Assessment Week 1 Nursing Assessment Week 2 (Baseline Admission Data) (Data from admission copies) (Data from Visit 2 copies) As this line depicts, the Admission Nursing Assessment of a patient in Consolo is the starting point of the logic flow (baseline data). The next Nursing Assessment (Visit 2) completed after the Admission will copy (clone), or populate, with some of the admission nursing assessment data, such as Physical Assessment data, History data, Pain Info data, etc. This permits the clinician to review data entered on the initial Nursing Assessment during the Visit 2 assessment (without having to open the Admission assessment), then change pertinent assessment data as is found on this current visit. Assessment data that is unchanged can be left intact and data can be changed or deleted accordingly. This charting method is called charting by exception. Be assured that any data changed/edited/deleted in the Visit 2 Nursing Assessment has NO EFFECT on the initial Nursing Assessment documentation. Any information added/changed/deleted in the Visit 2 Nursing Assessment will be saved exclusively in that Assessment. On Visit 3, when the Nursing Assessment is created, now the clinician will now view the data changes made on Visit 2. Consolo copies the Visit 2 data to the Visit 3 assessment, where it can be updated/changed/deleted to meet the assessment data found on Visit 3. 7 Page

8 For users without cloning permissions, there is a View functionality that allows a visual review of previous documentation in the specific section: Body Systems Findings and Related Documentation The sections below derive from the Nursing Assessment / Physical Assessment tab in the previous Consolo Versions. Findings are essentially the same as they were in the previous Nursing Assessment interface as separate Physical Assessment Systems. Any licensed nurse clinician, regardless of licensure, can use these Findings areas, whether assessing or observing. Items are checked off and text fields can be used to augment checkbox data. Below are the areas that will now be available for choice by the clinician to apply to their Clinical Charting Note: Body Systems Activity Musculoskeletal Finding Assessment/Observation data for Activities of Daily Living and Mobility. 8 Page

9 NOTE - The number values of ADL performance will be available for reporting and quality measure data in a future release. To clarify, this assessment data does not automatically populate to the rest of the patient chart. It is recommended that ADL performance data be added within the Assessment Summary text to be available to the Certification and that Plans of Care be developed addressing ADL Performance issues for each patient. This data will be available to the IDG Report/Snapshot via the Nursing Assessment text displayed in that Report or Snapshot. Body Systems Cardiac Circulatory Finding - Assessment/Observation data for basic cardiac and circulatory function. Body Systems Communication Finding - Assessment/Observation data for basic communication issues and patient orientation. 9 Page

10 Body Systems Elimination Finding - Assessment/Observation data for elimination issues, that is, incontinence, presence of catheters, BM function. Body Systems Neurology Finding - Assessment/Observation data for alterations in various neurological functions, Pupillary Response and Grasping. 10 Page

11 Body Systems Nutrition Hydration Finding - Assessment/Observation data for alterations in food/fluid intake, diet identification, documentation of tube feedings (Mini-Nutritional Assessment for focused assessment and scoring). Body Systems Respiratory Oxygenation Finding - Assessment/Observation data for alterations in respiratory function, identification of congestion. 11 Page

12 Body Systems Self Esteem Mental Status Finding - Assessment/Observation data for alterations in mental status and orientation, intensity scales measuring agitation, depression, etc. Body Systems Skin Integrity Circulation Finding - Assessment/Observation data for alterations in skin condition and peripheral circulation, identification of wound location (primary wound assessment/observation and care takes place in the Wound Assessment link) 12 Page

13 Related Documentation Coordination of Care This area is meant to be used as a way to document Coordination of Care activities per visit note. The nurse clinician can document a variety of activities that show Coordination of Care with the hospice interdisciplinary team, Patient/Family/Caregiver, Physician, etc. Use of this area is not limited to Nursing; any interdisciplinary staff member can make use of this section; for example, unscheduled IDT documentation can occur in this section. Nursing Pain History This documentation area was seen as the Pain Info tab in the old version of the Consolo Nursing Assessment and contains all the same documentation choices. For use on Admission and follow-up assessment/observation where and when appropriate and includes IV/SC therapy. 13 Page

14 Nursing Related Observations Assessment/observations choices for Safety, Body Image, Labs and Universal Precautions are located here. Nursing Summary Nursing Summary Notes function as the location to document Admission and Recertification Summaries for the patient Certifications. Discharge Planning is in this area as well. (cont d) 14 Page

15 Vital Signs Measurement As in the previous Nursing Assessment version, all measureable Vital Signs and Performance Scales are documented in this location. Please note Height is entered in Inches and BMI calculation will be display accordingly. 15 Page

16 Scales Reference links are now located under Related Links at the top of Clinical Charting Note screen: Nursing Health History This area remains as a free-text location for documenting past medical and nursing related history information. This area is most useful for all admission comprehensive nursing assessments. 16 Page

17 Mini-Assessments The optional mini-assessments are now part of the charting choice index and function completely the same as previously. Any mini-assessment completed within the Clinical Charting Note will now become an integral component of that Note. Previously, these were separate and only related by Effective Date. Morse Fall Assessment (Morse Fall Scale) Skin Integrity Assessment (Braden Scale) Teaching and Learning Assessment 17 Page

18 Pain Observations The Pain Observations can be completed by ANY discipline to document assessment/observations as necessary. The Comfortable Dying Measure questions for NQF 0209 have been added to the section. Be advised that multiple Pain Observations can be documented by adding multiple sections to a single note. Body Site area in the Pain Observation section 18 Page

19 It should only ever be necessary to create a Body Site ONCE. Do not create a new Body Site each visit. Once a Body Site is saved, it will be available in the Body Site drop-down box in all future Pain Observation entries. Wound Assessment The Wound Assessment section contains related wound care documentation choices. As with the Pain Observations, multiple Wound sites can be documented in a single Clinical Chart entry as necessary. NOTE As was the case previously with Body Sites identification in Pain Observations, do not create a New Body Site at each assessment. Establish Body Site names once and then always document to the same body site names under the Body Site drop-down until resolved or through to the end of the patient s care. 19 Page

20 Summary of Clinical Charting Note Once created, the entire Clinical Chart Note summary will display for clinician review each completed section will display under its own header: If the Clinical Charting Note requires a correction, click Edit this Clinical Chart under the Related Links drop-down at the top of the page: 20 Page

21 Make any corrections needed and re-save. To view a history of all Clinical Charting Notes, click the Clinical Charts link on the status bar: Clinical Charts history page and description: Adding Electronic Signature To add electronic signature of the clinician from the history page, click the View icon on the note that is planned to be signed. Once on the View page for the Note and the clinician is sure the Note is complete and correct, click Related Links at the top of the page note the Add Your Signature link: 21 Page

22 Click OK at the confirmation prompt: Note applied electronic signature to the bottom of the Note: Once the electronic signature is applied, the Clinical Charting Note can no longer be edited ever again. No corrections or edits can be made by the creator of the note and no other Consolo user can enter the Note and change any data. This means that the Note is locked down permanently. To address after-signed Note errors or additions, it will be necessary to create a new updated Clinical Charting Note to enter a correction or create an addendum. This emulates traditional clinical note corrections made in paper charts where post-dated edits are never permitted. Note the appearance of the history page Edit icon: Users are encouraged to review every note created to insure clinical accuracy before applying electronic signature. Also, be sure to click Reset within any clinical chart entry containing unwanted or duplicated sections PRIOR to creating or updating. Once saved, unwanted duplicate sections cannot be removed after the fact. 22 Page

23 Clinical Summaries The history for each Mini-Assessment completed throughout patient care will now be accessible from each Patient Homepage under the Clinical Summaries section. To review a history of clinical assessment entries, click on the desired link from the homepage. In this example, we will choose Wound Assessments. By clicking on the Wound Assessments clinical summary link, the following page will display. Note each Clinical Charting assessment entry is sorted by date and Body Sites addressed per date. For large lists of assessments, there is a small Search box where entries located per date, Body Site, etc., by typing in the desired information: Click on the View icon ( ) to open this specific assessment: 23 Page

24 Remember, once a Clinical Chart Note is electronically signed, all components of the Note are no longer editable. For any Mini-Assessment in history that has been part of a Clinical Charting Note that has been electronically signed, there will no longer be any edit ability possible. An example of this is below: All of the other Mini-Assessment Clinical Summaries function in the fashion described above. Please note the Clinical Summary for Vital Sign Measurements. This summary was added to take the place of the prior Consolo version s Nursing Assessment history page and provides a one-click historical view of all Vital Sign measurements added to Clinical Chart Notes over time. See the example below: 24 Page

25 Certification and Comprehensive Nursing Assessment For new admissions to hospice, Benefit Period 1 only, the Tag as Comprehensive feature for associating the specific initial Nursing Assessment Clinical Charting Note can be found as depicted below. - Create the Clinical Chart Note that includes all Nursing Assessment information to stand as the comprehensive body assessment. - Create. - Review the data summary page after creating to insure all entered information is correct; click Related Links as shown to find the Tag as Comprehensive functionality. Click Tag link. - Click Clinical Charts shortcut link to return to Clinical Charts history. - Note Legend at bottom of History page for Comprehensive Assessment. - Note Legend icon applied to specific Note Tagged as Comprehensive. 25 Page

26 When editing the Certification to associate the initial body assessment, users will see the following: 1-2- Clicking Show/Hide next to the Associated Nursing Clinical Chart will open choices of all the available Clinical Charting entries meeting the definition of a Nursing Assessment; choose the desired Clinical Charting Note to be applied to the Initial Certification (on Admission, choose the assessment Tagged as Comprehensive): 26 Page

27 Clinical Charts Link To see a historical list of all Clinical Charting Notes per patient, click the Clinical Chart link from the homepage as depicted below: All Clinical Notes will display in history on a single page: To view Clinical Charts entries for all active patients, click the Patients tab/clinical Charts link: 27 Page