The Pros and Cons of Digital Charting Guest Author Helen V.

Calalang-Javier, MSN, RNC, IBCLC

Often times, time management is a challenge to new staff or even staff that has been in the workforce a long time. A new electronic patient record documentation system (EPRDS) was implemented in the hospital where I used to work and most staff attended the in-service. The EPRDS is familiar to the nursing staff in this hospital, but most people needed a refresher course on this new version of documentation. The previous program was initiated five years ago.

The new program is an upgrade of the current electronic patient record documentation system. A new feature of this program is the direct physician order entry. The physician will now enter the order in the new documentation system that goes directly to various disciplines or departments where it is reviewed and processed. For example, the patients diet order will go to the dietary department where it is reviewed, processed and the diet is delivered to the designated unit. When the physician orders medication, the pharmacist will review it, and sends the medication to the designated unit. This direct order from the doctor to the pharmacy will ensure that the correct medication and dosage is delivered for the nurse to give to the patient. Because the pharmacist is the one who interprets the doctors order and it is the pharmacist who verifies the order. With this new process of medication transcription, a medication error is most likely minimized or eliminated. The EPRDS facilitates review of the patient records, advocacy of the patients needs, and collaboration of nursing care with other disciplines because duplication is reduced thus time is well spent. In addition, because it is a digital record, time is saved by not having to search through paper records. In addition it is cost effective to the organization.

However, there is a new challenge that arises among the staff in the use of

the new electronic documentation system. Learning the new icons and the new format can be tedious and time consuming. Combining computer proficiency and fulfilling direct patient care can be challenging each day. Spending time just completing the documentation on the computer leads to less time spent at the bedside. A good knowledge and application of time management skills is very important.

According to Stephen Covey, who wrote the book on The 7 Habits of Highly Effective People, time management is the ability to organize and execute around priorities. When providing patient care at bedside, nursing tasks must be prioritized in order to provide safe patient care. Direct patient care, patient education, and especially nursing documentation are the important aspects of a nurses daily routine and must be done with accuracy. As the saying goes in nursing, If it is not documented it is most likely not done. Additional activities such as attending committee meetings, making nursing referrals, and attending mandatory classes can take up the nurses time and delay completion of nursing tasks. All these must be taken into consideration when organizing and prioritizing activities.

Tips for digital documentation Keep the electronic documentation quick reference guide handy. Ask for assistance from the superuser staff. Set up the digital personal patient list. Set the goals for the day. Place your patient information timely. Review entry notes for accuracy. Safeguard password and logout if moving away from the computer to see patient.

Just remember that time is precious. As Napoleon Hill, the famous writer said, Do not wait; the time will never be ''just right.'' Start where you stand,

and work with whatever tools you may have at your command, and better tools will be found as you go along.

A Caring Nurse

Guest

Author

Helen

V.

Calalang-Javier,

MSN,

RNC,

IBCLC

Nothing is more worth recognizing than nurses accomplishments big or small every day and thanking them for keeping the profession of caring to move on.

Nursing is a noble profession and nurses have contributed their commitment and dedication to their patients, giving comfort, support and love. Why is caring unique when given by the nurse versus given by just anyone? Often times, we hear the common expression; I care about you, or I will help you overcome this. The nurses job of caring for patients is a physical manifestation of a caring attitude and calling. What then is it in the care given by a nurse that is so powerful that it can actually lead to the process of healing? Dr. Jean Watson is famous for her philosophy and science of caring and in her book published in 2005 called Caring Science as Sacred Science, she discusses the concept of caring and healing for health professionals based on moral, philosophical, and scientific framework. According to Dr. Watson, a harmony between science and the humanities acknowledges a deeper value of quality of living and dying that involves ethical, physical, moral and psychological components. Dr. Watson identified ten carative factors as the core processes involved in the professional practice of caring. These core factors are:

Faith and hope Humanistic system of values

Sensitivity towards others Trust Expression of positivity and negativity Problem solving Promotion of learning relationships Provision of support, i.e. spiritually, physically, emotionally, etc. Fulfillment of human needs Promotion of transpersonal caring and love

The caring energy is powerful that enhances healing with the core factors involved in the process. The basic idea is that all around us is made up of energy and everyone emits some energy. The nurse emits a much higher frequency of caring energy than the energy of a sick patient that converge into conscious healing process thus, tapping on the inner healing field of the patient. Once the inner healing field is touched, the healing process begins. As a professional nurse, one is equipped with nursing knowledge with the integration of the clinical carative factors, critical thinking skills, and the consciousness of caring that promotes the caring-healing relationships with the patient. This conscious caring attitude and skill is enhanced through practice over time. The caring energy that resonates from the nurse to patient restoring ones normal health is incomprehensible.

Showing how one appreciate and value the contributions of nurses to the caring nursing profession will surely provide encouragement to keep the caring energy flowing!

Fall Risk and Prevention As many nurses are aware, falls are a big problem. They effect not just the health and lives of our patients, but the financial health of our institutions. The experienced nurse has seen this firsthand. The inexperienced nurse is warned of it constantly. Just to be clear, let us look at some statistics. Falls account for 70% of accidental deaths in persons 75 years of age and older. (1)

A 2004 study conducted by JHU found that short term risk of single and recurring falls was three times higher for the two days following a medication change. (2)

Ten percent of fatal falls for older adults occur in hospitals. (3) Goal 9 of The National Patient Safety Goals from JCAHO is to reduce the risk of patient harm and to implement a fall reduction program. (4)

These four statistics are enough to ensure that no matter where you work, you have had the pleasure of taking a mandatory course on fall prevention. You have had to fill out paperwork, take quizzes, and document your preventive actions each shift. If you have not been doing this, then your institution is out of compliance and will be implementing these strategies soon. One of the first things to do is ask them on admission if they have had any falls in the last year. If they have, then they are automatically a high fall risk.

(5) Some other more obvious things to assess are visual impairments, use of cane or walker, and urinary urgency or incontinence. One of the less obvious questions would be concerning medication use. If the patient is on a benzodiazepine, then they are at high risk for falls. (5) Any blood pressure, seizure, glucose, or pain medications increases their fall risk. Assess the patient for neuropathies and residual weaknesses from strokes as these can also be contributing factors to loss of balance and weakened gait. Discuss with your new admission the type and frequency of physical activity normal for them. If they are going to be more immobile during their admission than they are at home, then a referral to physical therapy is appropriate to help them maintain a level of ADL capacity for safe discharge home. After you have assessed your patient on admission, your organization will probably have some type of chart for rating their risk. This should easily allow the staff following you to see what you have assessed and follow the appropriate interventions. For every patient, every shift you work, you will be doing a fall risk assessment. The risk to each patient can vary from hour to hour, and is something that you must become aware of in your daily practice. If a medication has changed, a patients level of consciousness has changed, they are experiencing pain or shortness of breath, all of these can change the risk. Imagine you are an older woman who has been placed on a new medication that increases urinary frequency. This is a new problem and you are embarrassed by how often you need to use the call bell. It is likely that you may attempt to go the bathroom independently. Another scenario would be the COPD patient. They may need to stand to urinate, but be weak from their condition. They may misjudge their own capacity and balance. If your patient is a low risk, then you need to focus on education to keep them at a low risk level. This can be in the form of handouts or verbal reminders. Every patient should be required to notify staff when they are

going to be ambulating in their rooms. If a patient has demonstrated safety, then this can be taken on a shift by shift basis. Other things to remind low risk patients about include wearing no-skid slippers or shoes, getting up slowly from supine to upright positions, and any equipment in the room that is on wheels such as tables or poles. If there has been administration of a medication that could change their balance, cognitive functioning, or cardiac response, be sure to warn them. This is especially important with pain medications. Many of us forget that once a patients pain is relieved, they may assume that they can resume normal activities, while we may be expecting them to be lying still. Be sure to communicate your expectations and listen to their perceptions of the plan of care.

If your patient is high fall risk, then you need to do as your institution mandates. Some of the more popular interventions include no-slip socks, flags on the chart and doorways, hourly rounding, and bed alarms. Be sure to involve visitors to the patient in this vigilance. Explain to them how dangerous and common falls are so that they truly understand the risk. This will engage them in doing something helpful to the patient and make them feel included in the care plan. Use of personal alarms may be something available to you for the frequently confused patient. These systems can be invaluable in protecting your patient and saving them from injury. Be sure to only use the top two rails of the bed! Anything else is considered a restraint by law and will necessitate following your restraint protocols. Keep commonly used patient belongings within reach, as well as the call bell. It can be helpful to have the patient demonstrate proper call bell use during your initial rounding. This will allow you to assess their ability and give them a motor memory reminder when needed.

When you do get your patients up be sure to use care and caution. Do not hurry them. They are not moving at your pace, ever. You have been whipping around the halls, multitasking, and planning three steps ahead.

They have been lying bored in bed or waiting patiently for someone to come and help them. Focus on the task at hand. Remind them to tuck their tailbones under and lift their chins. This causes them to reverse the shuffling hunch that many patients pose. I often joke with my patients when they first stand up to show me their boobies! Obviously, you want to be sure that this wont offend them, but most of them laugh and then stretch their backs into the proper position for correct balance. Many of them will even comment that it feels so good to stand up like that! Notice if your patient is shuffling their feet. This is often a sign of pain or fear. Be sure to address this by establishing trust, making eye contact, keeping a firm steady hand on them, and talking to them about their experience.

Having said all that, it sounds time-consuming, doesnt it? It isnt, really. The bottom line is a good assessment at admission, another common sense assessment at rounding each shift, and monitoring the safety measures in place. Combine those with a positive attitude and careful assistance when ambulating your patient, and you will have significantly reduced your patients risk of fall, injury, and death.

(1)

Am

Fam

Physician.

2000

Apr

1;

61(7):

2159-68,

2173-4.

(2)http://www.cdc.gov/HomeandRecreationalSafety/falls/FallsPreventionActivi ty.html (3)http://www.ihi.org/IHI/Topics/PatientSafety/ReducingHarmfromFalls/ (4)http://www.jointcommission.org/NR/rdonlyres/D619D05C-A682-47CB874A-8DE16D21CE24/0/HAP_NPSG_Outline.PDF (5)Tromp AM et al. Fall-risk screening test: a prospective study on predictors

for falls in community dwelling elderly. Journal of clinical epidemiology, 2001, 54:837-844.

Hand Sanitizing Foam Nurses are busier than ever, but so are the bacteria and viruses with which we battle. They are more resistant and getting more so everyday. How many of us have at least one isolated patient on our modules when we work? The hand sanitizing foam is ubiquitous at all institutions, but are we using it properly? Do we put our patients at risk by going from room to room without foaming or washing every time?

I spent my last shift paying particular attention to how often I used hand foam. I found out something interesting. It feels odd to use it as often as we should. My hands got slimy. It was not realistic to use it the way the administration intends. Instead, I ended up washing my hands with soap and water about every third visit to a room. This added some time to my routine, but made me feel much cleaner.

The foam, as most know, is to be used anytime you leave a patient room, unless your hands are soiled, in which case you should use soap and water. The other exception is for cases of c. difficile infection. This also requires soap and water, as it is a spore, and is not killed by the foam. The foam is also to be used at other times, but the focus is on patient contact. Think about how you use your hands when you enter a patients room. Do you touch the beeping IV button? Do you touch the button to silence the call bell? Do you set your papers down on the table? Do you use your pen after

you have touched the patient, before you wash? Do you clean your stethoscope between patients? Do you only use the foam after you take off gloves and not when you have done something you dont think of as unclean? All of these are pitfalls into spreading disease, increasing length of stay, and endangering your patients.

Some hospitals currently track the amount of foam used, but this data does not give information about when the foam is being used, only how much of it. Another way hospitals survey their staff is to assign staff members to observe, record, and report about their co-workers. The best of these programs focus on the positive, rewarding those who are consistently in compliance by recognition and compensation ranging from prizes to tying it to pay increases. Virginia Commonwealth University is starting a sensor program to track foam usage by health care workers. The sensor notes the presence of ethyl alcohol, blinking green or red, depending on the finding. (1) This opens up an arena of tracking not before used, and shows the importance of getting into the habit of fitting this step into your routine now.

Reference: (1) http://www.physorg.com/news172334382.html

Political Activities for Nurses - Get Involved Guest Author Bethany Derricott, BSN, RN

The excitement is in the air as President Elect Barack Obama prepares to take office on January 20th. People from all over the world recognize the significance of this historic occasion, but how many really understand the amount of work that will be necessary to change the face of the political

scene in the US, especially in regards to health care? I would venture to guess not many. Fortunately, nurses can play a unique role in creating change within the health care system and nursing practice. We not only understand various facets of the health care system, but we also understand the day-to-day issues that affect patients and their families, as well as nursing practice.

So, what can nurses do to affect real change within the political world? The answer is a lot! Below is a list of political activities in which nurses can participate in to change not only the way nursing is practiced, but also the way health care is practicedSo, get involved:

1. Apply to be a Fellow in the White House Fellowship program. This paid position allows participants to work directly with White House Staff and high ranking government officials to affect change in legislative policy. 2. Attend the Nurse in Washington Internship (NIWI). This is a yearly workshop sponsored by the Nursing Organizations Alliance which teaches nurses about the legislative process and how to influence health care policy. 3. Become a member of the American Nurses Association. The ANA is the largest professional organization in the U.S. that legislates and supports nurses and nursing practice. You can also get involved with specialty nursing organizations that participate in political activities, such as the Association of Womens Health, Obstetric and Neonatal Nurses, the American Association of Critical Care Nurses or the Academy of Medical Surgical Nurses, to name a few. These organizations develop policies and work to make changes within the health care system.

4. Research health care and nursing issues that are currently being considered by Congress. Start by visiting the online Thomas Library of

Congress. Contact the State Representative or Senator supporting the bill you are interested in to find out ways to get involved.

5. Contact local political leaders. If you are interested in more local issues, you can contact political leaders in your area to learn about current issues and ways to get involved in activities that will support important health care and nursing legislation.

6. Start a letter writing campaign or petition in your hospital or health care organization. This will help to support legislation that is important to your practice. Letters and petitions can be sent to local, state and/or federal leaders.

7. Research the internet for organizations that support issues in which you are interested. For example, if you are interested in issues related to HIV/AIDs, you could contact The AIDS Institute to assist in activities that will further important legislation, or if you are more interested in patient advocacy, you can contact the Patient Advocacy Foundation to locate resources that will support patients and their families.

8. Write a letter to the Editor of a local or national newspaper. Use this forum to spread the word about issues important to nurses and patients. 9. Write an article for a nursing journal or magazine. This will help to alert other nurses about important political issues.

10. Call local or national radio talk shows. This is a great way to let the public know about important issues.

11. Lobby the manager or administrator of your own health care

agency about issues that directly affect patient care and nursing practice in your facility. Sometimes starting right in your own backyard is the best way to initiate change.

12. Research issues or policies that are important to your practice. Provide a short in-service to coworkers to educate them about the issues you explored. 13. Educate others. Nurses know that educating others is a great way to affect change. For those of you who do not have the time to participate in lengthy legislative activities, simply find a legislative bill or advocacy organization that interests you and send an email about your findings to coworkers, friends and family. Ask them to pass the information on to others.

Not all political activities require a visit to Capitol Hill; many only require the willingness and creativity for which nurses are known. So, get involved!

Why Should I Document Education? How many of us have heard the adage, If it isnt documented, it isnt done? All of us, right? So, then, why do so many of us leave out documentation of education? It is a standard of practice expected by the Joint Commission and the ANA. One hallmark of professionalism is accountability. Documentation is your accountability. It is what separates you from the non-professional and holds you responsible. Taking the time to document the efforts you have made at including your patient and their families in the plan of care will also help you focus your nursing care toward the subjects that have the most impact on outcomes and lifestyle changes.

When you give a cup of medications, do you know what you are giving? Have you thought about why that particular patient is receiving those particular medications at that particular time by that particular route at that particular dosage? Since you have, then why not talk about one of them when you administer it? Your dialogue would reflect your professional role, establishing a sense of trust and knowledge between you and your patient. When you offer a cup of fresh water to your patient, do you remind them that you are documenting how much they eat and drink? When your patient hurts and you ask them the score on your institutions pain scale, do you document that as education? These are all examples of how we are already doing the work, but not giving ourselves credit for it.

If you have documentation by exclusion, then your facility probably has a computerized flowchart for education documentation. An example would be a box where you choose from a drop-down menu of topics covered such as safety, medications, or treatments. Then the next box would include the way you taught, such as verbal, written, or demonstration. Documentation of who was taught the information should also be included. The last component is how the education was received. Did they ask questions, verbalize understanding, or were there barriers to learning such as denial or severity of illness? All of these pieces follow the flow of your care. You assessed the need for education, the willingness of the learner, who was learning, and how they received the knowledge you imparted. This is the information required by your professional licensure and should be documented for each patient, every shift.

We are shortchanging our own profession when we think that it is less than important to document education. This is what we went to school to learn to do. Anyone can push pills and change dressings, but only a professional can

educate and change lives. You have the opportunity to empower your patients and improve their outcomes and quality of life.