If asked, I would venture to say that almost every nurse would be able to state that they have either heard or been a party to a shift report that included; they’re ok, they’re ok…or no change, no change…
In hindsight, why didn’t we just discuss those residents with changes thus improving efficiency? As always, hindsight is 20/20. Luckily with an EHR such as PointClickCare® we have the opportunity to capture even more efficiencies by utilizing tools built into the software providing a natural workflow.
Sample Skilled Nursing Workflow
I envision the workflow as follows (based on your configuration and security):
Arriving prior to your shift start time allows for you to log into PointClickCare®
Read any Secure Conversations that may be available
Read the Facility Bulletins for non –HIPAA related postings
Read the PointClickCare® announcements making note of any maintenance down times and/or any upcoming updates to which you can review the clinical documents to see what is changing
Click into the Clinical tab navigating to Care Management
Read any communications posted for internal use only including HIPAA related information
Select current shift or the hyperlink for 24 hr. or 72 hr. report reviewing the report for ADT’s (Admission/Discharge/Transfers) that may have occurred while you were off, bed availability, full Progress Notes (PN), weights/vitals, immunizations and User Defined Assessments (UDAs) completed during the report type period selected
Making note of anything you wish to follow-up with the nurse currently on-duty
Back to Care Management
Review all areas which I am responsible for (example: High Risk PN’s such as Behaviors/Infection/ Weight Change/Skin/etc.)
Point of Care (POC) Assignment: how is the shift doing on documenting Activities of Daily Living (ADL), are reminders needed or is there an issue of incomplete documentation prior to the Nursing Assistants leaving that should be addressed?
Clinical Alerts: are there any alerts that have been triggered that need to be followed up on and cleared? (be sure to change the default of 48 hrs. via dropdown to see all alerts up to 90 days)
Immunizations: are there any outstanding results/administrations or second step of a TB that need completed?
eMAR status: any assignments not appearing as complete (green) if so, ask the nurse on-duty if there is an issue
Order Alerts: are there any alerts that have been triggered that need to be followed up on and cleared? (be sure to change the default of 48 hrs. via dropdown to see all alerts up to 90 days)
There are many additional areas within the Clinical Dashboard depending on your role that you may be responsible for and should review at this time.
Back to Care Management
Weights and Vitals: These areas will breakdown each weight/vital with exceptions for each resident based on the vitals entered as well as Baselines entered and the facility’s configuration for exceptions. Exceptions should be reviewed for even subtle changes that could be the early warning of a resident exhibiting changes, allowing staff to possibly identify an issue prior to it manifesting and requiring a transfer to the hospital
Review exceptions, follow-up and clear any alerts once following appropriate care path
Back to Care Management
Review Scheduled: look for any residents in your assignment that you need to complete the assessment on
Color coded in Red - they are overdue
Color coded in Black - they are due
Color coded in Grey - they are not due yet
Review In-Progress for any UDA’s that have not been properly resolved if you were the person allowed to complete that function (remember without selecting the appropriate button ( Save/Sign/Lock and Exit) the next assessment may not trigger based on configuration
Completing this review of what is already available in the EHR, you are now ready for the last minute updates from the on-duty nurse and ask any questions that may have come up from your review as you prepare to count narcotics and hand-off the keys.
Once completing the report with the nurse going off-duty you are now prepared to provide verbal report to your Nursing Assistants, post any communications needed for the team in the Communications section under Clinical Communications as well as add/update any Tasks (assuming Tasks or POC is being utilized within the system).
There are vast opportunities by utilizing the tools built within PointClickCare in the form of dashboards, reports and portals that can assist you in your day-to-day functionality. Therefore, plenty of variances to this workflow are possible based on configuration of the individual PointClickCare database, end-user Role access and needs. However if you were to use these basics, you are able to quickly and easily read what has happened, determine your course of action and provide direction to your team in a more informed, productive and efficient manner. While implementing this process, staffs have stated it made them feel less rushed and better prepared to provide the necessary care while decreasing the time that was previously spent on that all important verbal report, “no change, no change…”