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Horizon Expert Documentation (HED) On-line Nursing Documentation

Horizon Expert Documentation (HED) On-line Nursing Documentation. A How to Guide For IV Therapist. About HED: Nursing staff enter Vitals, I&O, Assessments, Interventions & Admission History data in HED. This data will be saved to Starpanel.

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Horizon Expert Documentation (HED) On-line Nursing Documentation

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  1. Horizon Expert Documentation (HED)On-line Nursing Documentation A How to Guide For IV Therapist • About HED: • Nursing staff enter Vitals, I&O, Assessments, Interventions & Admission History data in HED. This data will be saved to Starpanel. • Data from monitors (now) and Vents (Jan. ’06) downloaded into HED (nurse acceptance required). • Medications and teaching will be documented on a paper teaching record for now. • When transferring to units not live on HED- reports will be printed of charting in HED. • Timelines • 5N, 6S & 7N were implemented winter 2005 • 8A,B & C implement Jan 2006 • MICU, 8N&S, S3400, Subacute, CRC, 10S implement Feb 2006 • All areas to be implemented by May 2006

  2. Getting Started Sign on to workstation, click on GO TO DESKTOP Double click HED icon- HED will open to the patient census for current unit Single click patient’s name Step 3. Click Chart to display white boxes to document. Not necessary if white boxes already displayed. Click drop down box to change to a different patient. Step 4. Click Show all to display all items in IV Lines category. HED only displays items that have been charted.. Step 1. Click Assessment/Intervention tab to chart an IV. Note there are 3 (ICU, Peds, MedSurg) Click Show all if IV lines not in gray menu. • Step 5. Verify time is correct- defaults to current time. • 2 ways to edit time: • Use up /down arrows • Double click & type to edit time. Step 2. Click IV lines in the left gray menu bar. Menu is like table of contents for assessment/intervention

  3. CHARTING AN IV LINE Click one or more items from drop down box. Click again to deselect Step 6. Click Drop down box & click to make selections). Step 7. Click Annotation icon, to display area to type a short note. This will appear as a yellow post it note once data is saved. IV Site Intervention section contains Discontinued per nurse, flushed, # of attempts etc. Step 8. Click Save button when done. Review documentation MAKE SURE TIME IS CORRECT. Edit as needed. Step 9. Click Confirm to save data. Review data charted. Hover over item to see entire text stead of abbreviation or yellow post it.

  4. Charting a Dressing Change • Follow Steps 1-4 from the previous slides, Dressing change is located under IV Site Intervention. • Make sure you are documenting the Correct IV Site, there could be several sites. For Instance: IV Site #1 could belong to a PICC Line, IV Site #2 could belong to a Right Basilic. See How to Review Data (Slide #5) to chart appropriate IV Site # Step 5 – After Steps 1-4 from Previous Slides, Click ON IV Site Intervention Step 6 – Click in the box and a a Drop Menu will appear. Scroll up and down and choose the appropriate interventions. Step 7- Click save and confirm.+

  5. OOPS …. How to Edit Step 1Click item to be corrected Current documentation - This section can’t be changed. Edited items appear within parenthesis. Step 2: Click item & make edits or additions. Can only change your charting. Inactivate deletes documentation- use this if charted on the wrong pt. Step 3: Click OK to save. Reviewing IV Site will let you know which IV Site # belongs to which IV. For instance: IV Site #1 = Left Basillic Reviewing Documentation Click on Review ( in toolbar- top of screen) Click Items to be displayed ( Vitals/i&O/Assessment will display IV Category) Review Info. Right click to display entire text.

  6. Common Mistakes and questions • Not changing time to match time intervention actually done. • Remember, HED defaults to current time/date. • Not documenting all items needed for an intervention. • Remember to click on SHOW ALL for the category to display all items. Failing to show may result in missed charting. • Exiting incorrectly from HED. • Do not use the “X” in the upper right window to exit HED because there is not warning if data is unsaved. • PROPER WAY TO EXIT HED: • Click FILE in the upper tool bar, Click Exit. • This method ensures a warning if there is unsaved data. How do I Change Census or patient Click on Drop down & display units. Click on unit. Click on patient & begin to chart QUESTIONS? Contact the HELP DESK- 343-4375 Or HED support person during implementation support on a unit.

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