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HED DOCUMENTATIN CHANGES Education Tab: Safety/Fall Risk

HED DOCUMENTATIN CHANGES Education Tab: Safety/Fall Risk. Start With the Education 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).

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HED DOCUMENTATIN CHANGES Education Tab: Safety/Fall Risk

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  1. HED DOCUMENTATIN CHANGES Education Tab: Safety/Fall Risk Start With the Education 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.

  2. The Education Tab now follows the Priority Problems format. Identify the type of teaching and who received your teaching as well as other pertinent information. If necessary, use the post-it note to annotate additional comments as usual.

  3. Safety/Fall Risk Documentation • In training region, there is a separate tab for Safety/Fall Risk documentation. This area of documentation will be embedded within the Assessment tab at go-live. • FIRST, scroll to bottom of the Safety/Fall Risk Assessment, and complete the Morse Fall Risk Screen. • Morse Fall Risk Screen only gets done at admission, change in level of care/change in condition, post fall event • The score will automatically tally for you • Use the hover-over feature to help guide your documentation

  4. The Safety Risk Assessment and appropriate documentation need to be done every shift and PRN. • Only need to document against applicable fields • CIWA will also now be done in HED • 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 • “Response to Safety Interventions” IS CHARTED AT THE END OF THE SHIFT!!! • CIWA Scale found in the Assessment tab • Score will display here as well

  5. 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

  6. Continuing down to Section 4…. • If applicable, document who you notified regarding safety concern and what the plan is • A new fall event is documented from here • Take the time to go into HED Train from the desktop to look at these changes. In HED Train, there is a separate “Safety/Fall…” tab in which you can practice • Go-Live is 10/16/12. The “Safety/Fall…” tab will disappear, and this section will be embedded within the Assessment tab

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