Changes to HEDEducation Tab

Safety/Falls Risk under Peds Assess/Intervention

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The Education Record Tab now follows the Priority Problems format.

Identify who received your teaching as well as other pertinent information. If necessary, use the post-it note to annotate additional comments as usual.

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Start With the Education Record Tab First

Upon admission, identify the appropriate Care Contacts for your patient. This information needs only to be entered once during the admission (unless there is a change).

The hover-over feature gives a precise description of the expected documentation to that area.

Safety/Falls Section: What’s Changing?

Safety assessment on every patient, every shift.

Falls Screen

o Adults: Morse Falls screen o Peds: Humpty Dumpty Falls

o on admission, q shift, and with condition changes

o Streamlined documentation of Restraint Safety Care

Safety Problems (Injury Risk, Violence Risk, Substance Abuse, and others) will be identified. o If a safety problem will be a key driver of nursing care for that patient, also initiate

as a Priority Problemo CIWA documentation will be available in HED for units that implement CIWA

protocol

Safety Interventions will be documented – things you: o Assess/Monitor/Evaluate/Observeo Care/Perform/Provide/Assisto Teach/Educate/Instruct/Supervise o Manage/Refer/Contact/Notify

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Peds Falls Assessment Score Auto-Calculates

Peds Falls assessment score will be auto calculated

Continue to chart Falls Risk Assessment Interventions for Standard or High Risk

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The Safety Risk Assessment and appropriate documentation need to be done every shift and PRN.

Only need to document against applicable fields You can start a Priority Problem from here, if applicable. Now

only need a Priority Problem if the safety issue is driving care or restraints in use

Document Response to Safety Interventions in Nursing Summary and Plan Priorities at end of shift

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NEW Safety/Fall Risk Documentation

Below Peds Falls Assessment, the new Safety Risk Assessment will display to incorporate everything related to Safety:

Peds Falls assessment will be auto calculated

Falls Risk Assessment included

NEW Safety Assessment to be completed qshift

Safety Monitoring Safety Care Implemented Safety

Education/Engagement Safety Notification/Care

Coordination

Contributors to fall or injury risks

Interventions for falls risk patients

Interventions for violence/injury

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Restraint documentation, located within Section 2 is streamlined:

Document the “Restraint Status” Checking “done” to “Restraint Safety and Comfort Care” reflects

that you have done all the descriptors seen when using the hovering feature

Document against both of these fields Q2H

1. All patients are on Standard Falls Precautions_____ 2. Falls risk assessment is done on admission and at

discharge_____ 3. You will now be able to chart falls events on the

falls/safety tab____ 4. For high risk falls patients, interventions could include:

ambulating with the patient, monitoring medication side effects, keeping the room cleared, having the patient to wear yellow socks and yellow armband, and placing LAMP sign on the patient’s door ______

5. You can only start a safety/fall priority problem on the poc tab_____

6. Safety assessments are done q day_____

Answer the Questions: true or false