Making Information Flow

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Making Information Flow

• Presented by
• Deb Stroud, RN
• POC Clinical Specialist
• Mayo Regional Hospital
• Dover-Foxcroft, Maine

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Mayo Regional Hospital

• 25 Bed Critical Access
• 4 Bed ICU
• 2 Birthing suites
• 3 postpartum beds
• 18 Bed Med/Surg/Swing
• 24 hr ER
• 3 Suite OR
• Admits 1,200 (adc 14)
• Births - 187
• Emergency 13,000

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LIVE with CPSI

• April 7th, 2008 POC, MedVerify
• July 2008 E-forms live in the OR
• January 2009 E-forms use in nursing departments

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15 months after go live we stopped printing all
progress notes, graphic IOs and MARs.
(medication administration records) by
streamlining information using

• Flowcharts
• Electronic Forms
• MedAct
• Problem Lists
• Patient and 24 Hour Summary

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Including Ancillary Service Notes

• Physical Therapy / Rehab Services
• Cardiopulmonary
• Social Services
• Dietary

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Presentation GoalGet the creative juices
flowing by presenting the diverse communication
capabilities of flowcharts, electronic forms,
medACT , and problem list.
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Meeting Documentation Needs for Nursing
Indicators

• Risk for Pressure Ulcers
• Fall Risk
• Aspiration Risk
• Therapeutic Activities
• Pneumonia Risk
• Hygiene

• Nutritional Risks
• Immunizations
• Smoking Cessation
• Venous Thromboembolism (VTE)
• Restraints
• Risk for Abuse

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Help Me REMEMBER ?!?!?!?
DONE !!! With the help of communication ability
via Electronic Charts
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Reflexes in Flowcharts Create Nursing Order

• Braden Scale results Calculates in the
  flowchart if score is less than 17, on exiting
  - reflexes nursing order to the MedAct

Pt. Safety Productivity Staff communication
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Reflexes in Flowchart Send a CPSI E-mail
Notification

• Admit status change reflexes email via CPSI to
  the nurse manager and swing assistant
• They review the chart to assure all swing
  requirements are initiated.

Nurse selects answer Acute to Swing on
flowchart
Quality Care Staff communication
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Reflex E-mail Wound Form Started
To ensure correct staging, documentation, and
use of new standards, the nurse manager receives
a CPSI e-mail via a reflex through the flow chart
when a wound form is initiated.
Selecting answer generates reflex to send email
E-mail via CPSI
Quality Care
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What is a Reflex?

• Reflex is an automation option that can be
  attached to a question in either the Initial
  Interview, Physical Assessment, or E-Form setup.
  
• Maximum of 3 reflexes per question.
• Answers must have a numeric value assigned.
• Reflex can send e-mail, Create Order, Create
  MedACT order, or Create a Charge.

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How to Setup a Reflex

• CPSI Path
• (must be signed in to the Nursing Administration
  Department)
• From the Hospital Base Menu
• Print Reports
• Under Nursing Stations Functions select Nursing
  Chart Masters
• Under Miscellaneous Maintenance select Reflex
  Table

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Reflex Setup continued

• Select New
• (the code for the reflex is
  automatically assigned by the system.)  

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Reflex Setup continued

• Enter the name of the reflex in the Description
  field. 
• In the Answer Range field enter the range in
  which the reflex will be triggered.
• Select the time frame by entering the Time Range
  field. Options are All or Most Recent.

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Setting a Response to Reflex
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1
2

• Select the reflex from the listing, the reflex
  setup will display in the Reflex Responses
  portion of the screen. Options are Edit, New, and
  Delete.  (1)
• To add an item to the reflex, select New. (2)
• After selecting New, select the type of reflex.
  Options are Send Mail, Create Order, Create
  MedACT Order, or Create a Charge. (3)

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E-Mail Reflex Setup

• Mail To select where the mail is to be sent.
  Options are Clinic, Department, Employee, or
  Physician. 
• Enter the Department number, Employee number or
  Physician Number in the field next to the
  selected mail to option. 
• Enter the mail message to be sent in the Message
  fields.  
• The Multiple Times field allows the reflex item
  to be placed more than once.
• Select Prompt User and the system will display a
  prompt when the item is reflexed. 
• Select the Answer Range field to set the answer
  range for the reflex item if it is to differ from
  the answer range of the reflex itself.

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How to Attach Reflex to Question Setup

• Nursing Chart Masters
• Department (med/surg)
• Question Location
• (Initial Interview or Physical
  Assessment)
• Enter reflex in reflex box
• Attach value to answer

Question Setup screen
Answer Setup screen
Sends this question and answer to the physician
or nursing summary report.
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Reflex MedACT Nursing order

• Enter? In Item Number  
• Select the appropriate category. 
• Once the category is selected, the orders will
  display. Select the order from with in the
  category

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Reflex Orders

• Reflex
• Select Create Order
• Enter ? in Item number box
• Ancillary order look up will open.

Note The option to place the order appears
AFTER you leave the flowchart. Typically orders
are placed simultaneously with nurses charting.
This would possibly work well on a triage
flowchart.
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Reflex Charges

• Reflex
• Create Charge
• ? Item number
• Enter department in Item look up
• Select charge from Item master.

?
NOTE This charge does not show up on the screen
where the data entry clerk posts charges so this
can create a double charge on the patient
account. Include the business office in setting
this up to ensure correct item master number is
selected and they are aware of this reflex so
they do not charge for the same service.
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Did my Reflexes Send?

• Select Flowchart
• Select REFLEX
• Flow Chart Reflex Review will open

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Important information from documentation flows to
the Nursing and Physician reports

• Patient Summary prints 2x a day for use in
  nurse shift report
• Physician 24 Hr Summary prints _at_ 7am

Pt. Safety Productivity Staff communication Qualit
y Care
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Coded Flow Chart Answers Keep us informed

• Answers are coded to pull to the Physician or
  Nurse summary reports.

MUST Select the answer from the answer boxes
Then open the free text box to type comment
Answer set-up screen
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What Goes Where?
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Dietician Note
Social Service Note
Physical Therapists Note
Occupational Therapist Note
Nurses Shift Summary Note
Notification that a wound being monitored
Also Appearing Here Cardiopulmonary Pharmacy
notes
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During answer set up for Distinctive Assessment
select Nursing or Physician to designate which
heading the information will appear under on the
summary report
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How to Format Summary Reports

• CPSI Path
• (must be signed in to the Nursing Administration
  Department)
• From the Hospital Base Menu
• Print Reports
• Nursing Chart Masters
• Department (med/surg)

• Select 24 hr Summary table (Physician)
• -OR-
• Patient Summary Table (Nurse)

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Formatting Options
ICU can be different from Med/Surg and Obstetrics
and Peds.

• Select either A or B
• Since this is set up by Chart Type Each chart
  type can have different formatting options.

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Format B
Check Dist. Nursing Assessments Topic bar
will appear on the 24 Summary All answers Coded
Nursing will pull here
Checking BOTH distinctive assessments will pull
all the information to BOTH summary reports
Check Dist. Physician Assessments Topic bar
will appear on the 24 Summary All answers Coded
Physician will pull here
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Differences Between Summary Format A B
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(No Transcript)
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Format A

• Prints Portrait
• Intended for ICU type patients
• Gives 24 hr view from time of printing

Format B

• Prints landscape
• Provides more information for the general admit
  patient
• 24 hour view based on time you select as 1st
  shift start hour

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How we decided what would be included in the 24
hr Summary?

• Attended the Medical Staff meeting giving them an
  opportunity to identify what items they needed on
  
• Format B.
• Asked the Hospitalists if they would like ICU to
  use format A
• Physicians chose 10 Selected lab results

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How About E-Forms
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E-Forms have provided multiple ways to
communicate through Multi-app codes, reflexes,
and faxing AND ensure policy adherence.
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Initial Interview E-Form Saves Time
Facilitates Patient Safety.

• Improves productivity when more than one person
  can participate in the documentation process.
• Nursing assistant (CNA) can collect general data
• CNA documents room orientation
• RN reviews CNA documentation completes all
  history and assessment information
• Home Med List flowchart can be completed by
  another RN
• History questions pull from previous admits to
  new forms.

Pt. Safety Productivity Staff communication Qualit
y care
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Initial Interview is set up to ensure compliance
with assessment requirements provides patient
safety through knowledge of risks.

• Aspiration Risk
• Physical/Emotional Abuse
• Nutritional Risk
• Smoking Cessation need
• Wounds present on admission
• Hx of drug resistant organisms requiring special
  isolation
• Immunization Hx and assessment of need
• Anesthesia risks
• Surgical and Medical history
• Functional level and home environment
• Learning ability and needs assessment

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Examples CNA Section
Nursing Assistants may complete
Productivity Pt Safety
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Infection Control
Information in this section copies forward from
previous visits, quickly informing staff of
precaution needs helping to prevent unnecessary
exposure.
Sends E-mail to Infection Control nurse notifying
her to review the chart
Instant access to help window
Pt. Safety Productivity Staff Communication
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Sends E-mail to Cardiopulmonary Dept.
The numerical answers Multi-app to the
Dieticians physical assessment flow chart
Calculates and the total score indicates
nutritional risk. Dietician identifies risk and
comments on plan this answer appears on the 24
hr summary.
Pt. Safety Productivity Staff Communication Qualit
y Care
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Faxing
Physicians requested an improvement in the
communication of information when OB patients
were triaged and treated by the on-call
providers. This was accomplished by faxing the
triage form to the prenatal care provider after
each visit.
Quality care Productivity Staff Communication
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Rule out Labor Discharge Instructions
Our Problem Inconsistently providing discharge
instructions, education, and follow-up when a
mother presented to OB and was certified not in
labor.
Our Solution OB Triage E-Form has database
codes attached to key information that pulls
information to a patient education form
automatically. Nurses print the e-form after
completion and Page 3 is auto populated
creating the patient discharge instructions and
education.
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• 100 of the OB patients that are discharged from
  facility with ruled out labor receive
  instructions and education on care.
• Medication reconciliation
• Information about returning to the hospital or
  contacting their physician

Self populates I am so excited !!
Pt. Safety Quality Care
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Places Alerts on MedACT for High Risk Conditions
or Tasks
Reflexes are created based on answers in the OB
admission form sending nursing orders to the
MedAct (Kardex) and emails for consults.
Pt. Safety Staff communication Quality care
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HOW to create these communications in E-Forms
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E-form Path

• Nursing Administration Department Base Screen
• Master Selection
• Maintenance Menu
• Business Office Table
• E-Forms
• Reflexing

This will open the reflex creation windows as
shown previously. Create the reflexes and
responses as described (slide 14)
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Reflex can be attached to

• Check Boxes
• Drop Down Answers
• Radio Buttons
• Text Boxes
• Each control can have up to 3 reflexes

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Attaching a Reflex

2 Select the Reflex Tab
1 Create a label
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Select Magnifying Glass next to Box
Set a numeric value to the answer based on the
value set in your reflex
Select Reflex Reflex Number will populate into
code box.
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Multi-Application Codes

• Used to make documentation from an Electronic
  Form (E-Form) display on a corresponding question
  in Point of Care.
• Can be attached to a question in the Physical
  Assessment or Initial Interview flow charts.
• If the question is answered in an E-form 1st
  when the user opens the corresponding POC
  question they will have the option to change,
  delete, or keep the answer.
• IF the question is answered in POC 1st the
  answer will transfer to the E-form when opened.

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PATH Setting up Multi-App Codes

• Nursing Admin Hospital Base Menu
• Nursing Chart Masters
• Multi-App Codes

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• Select NEW
• Enter a CODE that is unique to the Multi-app code
  in this field.
• Tab to enter a Description

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Attach to E-form Question
2 Select Magnifying glass to open look up box
1 Create label then select Database
3 UNCHECK Form and Formless CHECK
Multi-Application Select the Code
Look-up Box
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Example of Multi-app Use
When dietician opens their flowchart, the
answers from the E-form Nutritional Assessment app
ear.
Nurses answer nutritional risk questions on
initial interview
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Final View in Dietary Flowchart

• Numbers pull from E-form
• Calculate
• Dietician is able to determine nutritional risk
  based on score
• NOTE Calculations ONLY WORKS in a Physical
  Assessment flowchart.
• Dieticians comments pulls to Physicians 24 hr
  summary

Pt. Safety Productivity Staff communication
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Other Ideas
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Cardiac Rehab
Pt. Safety Staff communication Quality care
Documents Education needs, Tools used, status of
understanding and any observations
All steps are listed on MedACT, Documentation is
entered into MedACT Items are completed on MedACT
leaving a constant view of what rehab level the
patient has achieved.
Education level on transfer / discharge
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Standardized Care in OR and PACU

• Forms designed based on standard care plan for
  patient in the OR / PACU
• Time Out reminder and Site Verification
• Implementation of Aldrete discharge scoring
  system.

Pt. Safety Quality care
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Surgical Care plan incorporated into form
Pop up window provides policy or standards of care
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As a documentation tool
MedACT
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Documentation of Activities / Care Reminders

• Therapeutic Activities for Swing
• Ambulation
• Hourly Rounding
• Turning q2 hrs
• Daily hygiene
• Fall Risk
• Meals
• Consults

• Extra Nourishments
• Equipment use
• Glucose Readings
• Vital Signs
• Intake Output
• Immunizations
• Future Tasks
• and much more

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Nursing and ancillary departments can view the
documentation of all activities at any time by
accessing the MedACT via the tab on the virtual
chart OR with the icon on their flowcharts

Select the item from the MedACT

Select Performed Document actions and patient
response.
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Viewing Documentation

• Required for SNF
• Ancillary dept view
• Nursing view
• MD report

Select activity
Select Review
Pt. Safety Quality Care Communication
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High Risk Alerts
Risk Level
Pt. Safety Quality care Communication
Interventions
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Problem List aka Careplan
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Why document with problem list

• Hospitals MUST ensure that the nursing staff
  develops, and keeps current, a nursing care plan
  for each patient. (Reg 482.23)
• Standardizes documentation of specific care in
  consistent location
• Proves utilization of care plan in daily care
• Easy to identify intervention and evaluation
  documentation
• Communicates progress of identified problems

Pt. Safety Quality care Communication
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Standardized Problem List

• Mayo Adult Problem List includes the 7 standard
  problems that are addressed on all adult admits

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ExampleDocumenting Education in OB
Select Intervention Document comment
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How do I see documentation?
Quality care Communication
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Appearance in Progress notes and Shift Summaries
Quality care Communication
Documentation of type of education
Education on infant hygiene
Moms return demo
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One More Communication Tool The White
Board

• Pt locator expanded uses
• Discharge orders
• Notifies nurses of completed orders
• Reassess times
• Flow through the Surgery suite

Reassess reminder courtesy of Cathy Schneider
Lincoln, Maine
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In Conclusion

• Flowcharts, Electronic forms, MedACT, and Problem
  lists when configured to complement each other
  create an electronic medical record environment
  that promotes increased patient safety and
  enhances quality care through reliable
  communication.

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TIP Sheets Available (just a few)

• Ancillary notes to 24 hr Summary
• Braden Scale order to MedAct
• OB Admit E-Form
• OB Triage E-Form
• Reassess times set to pt locator
• Documentation of Activities
• Initial Interview E-Form
• Adult problem list documentation

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THANK YOU !!!!!

• PowerPoint presentation CD or download
• Tip sheets available
• dstroud_at_mayohospital.com
• 207-564-4152 (office)

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• One thing is certain
• That is that the power of belief, the power of
  thought, will move reality in the direction of
  what we believe and conceive of it.
• If you really believe you can do something, you
  can.
• That is a fact.