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Making the Most of Nightingale NotesJEAN C DURCH, RN, MPH
TRAINING & IMPLEMENTATION COORDINATOR
How are you using Nightingale Notes?
Let’s Brainstorm!
What are the barriers to full use for your agency?
WEBSTER COUNTY ATTENDEES
Nightingale Notes FeatureWorking Well for You
Need an Update or Review
Do Not Use The Feature
Client Detail 5 1 Activity Detail 5 1 Help Screens 4 1 Time Tracking 3 1 2
Immunization Setup 1 4 1 not yetImmunization Entry 1 4 1 not yet
Scheduler 2 3Agency Values Setup 4 1
Employee Setup 5 1 Custom Tab Setup 3 2 1Using Custom Tabs 3 2 1
The Omaha System: Problem Classification Scheme 3 1 1
Intervention Scheme 3 1 1Problem Rating Scale for Outcomes 3 1 1
Pathways Setup 2 2 1Using Pathways 2 2 1
Billing Setup 5 How to Create Bills 5
Billing Clearinghouses 5 Ledgers 1 2 2
Designing Reports and Report Wizard 2 4 1Using On Demand Reports 3 3
How are you using Nightingale Notes?
Let’s Brainstorm!
What are the barriers to full use for your agency?
JOHNSON COUNTY ATTENDEES
Nightingale Notes FeatureWorking Well for You
Need an Update or Review
Do Not Use The Feature
Client Detail 7 Activity Detail 7 1 Help Screens 6 2 Time Tracking 5 3
Immunization Setup 3 5Immunization Entry 2 2 5
Scheduler 1 3 5Agency Values Setup 4 2 2
Employee Setup 7 Custom Tab Setup 5 3 1Using Custom Tabs 4 3
The Omaha System: 1 2 1Problem Classification Scheme 2 6
Intervention Scheme 2 6 Problem Rating Scale for Outcomes 2 6
Pathways Setup 3 5 Using Pathways 4 4
Billing Setup 1 4 4How to Create Bills 1 4 4
Billing Clearinghouses 5 3Ledgers 1 5 3
Designing Reports and Report Wizard 3 6 Using On Demand Reports 3 6
What can an Electronic Health Record (EHR) do for you? Patient Record
Data “counter”
Report Generator
Billing System
Scheduler
Reminder system
Employee files
Grant monitor/reporter
Community Coalition “Info Central”
Clinic Records
Immunization Records
Emergency Preparedness (Repository of Info)
Visions of an Electronic Health Record (EHR)
BASIC
Client Details “registration” data
Client “medical” data – Rx, Dx, Tx
Capture charting (Interventions)
Maybe Episode items: 485, OASIS
Not a different way to practice; just a different way to document
Visions of an EHR
BETTERCategorizes information to find easily & quickly
Uses standardized problem names and assessment of focus areas, interventions and evaluation of client
Measures effectiveness of care or client progress (e.g. outcomes)
Visions of an EHR
BETTERIdentifies gaps (Quality Improvement!)
Allows you to “Prove it”
Management System streamlined, e.g. Billing, Reporting to payers & Board
Visions of an EHR
BESTDrives the desired practice in agency with Evidenced-Based pathways, Standard forms (Tabs) for care and Pathways with “expected interventions”
Combines all clients or certain client types, or certain DX for instance, so we can “see” how a program or the agency is doing. (Performance Management)
Visions of an EHR
BESTProves that what you did improved the client quantitatively.
Provides the basis for “asking questions of the data” (Research)
Why is this better than Narrative? No arduous digging, reading, confusion.
No handwritten, illegible notes
May be less forms to fill out with relational data
Less paper forms with development
Improved ability to demonstrate who accessed record
Allows for consistent quality, e.g. practitioner to practitioner & time to time and controls omissions (Quality Assurance)
Using Your Electronic Health Record (EHR) As Part of a Best Practice Strategy in Your Agency
OUTCOME
OUTCOME
How the Omaha System Was Used
PROJECT OUTCOME
ReportingWORKING BACKWARDS FOR BEST RESULTS
Reports – Uses….Any More?
Nurse Management:
•Client Caseload
•Schedule
•Time/Activity/Mileage
Management:
•Caseload
•Audit Reports
•Omissions
•Billing
Program Reports:
•Grant deliverables
•Grant activities for reimbursement
•Number served by x and y and z
Record Review:
•Completion for Compliance
•Meeting standards
•E-signed
•Charting ready for billing
Pathways and Reports
Hot Tip! Create a unique prefix for your report name that you use to pull that information only.
TB Skin Test: 0-5mmTB Skin Test: 5-9mmTB Skin Test: 10+mmTB Skin Test: administered to L forearmTB Skin Test: administered to R forearmTB Skin Test: read as negativeTB Skin Test: read as positive
Secrets to pulling data from Pathways!
Pathways and Reports
Build the answer or range you want to be report right into the pathway’s guide.
o The child is up-to-date on their immunizations
o The child is NOT up-to-date on their immunizations
o Lead level: 0-4 no risk
o Lead level: 5-10 moderate risk
o Lead level: 11+ high risk
Secrets to pulling data from Pathways!
Pathways and ReportsSecrets to pulling data from Pathways!
Pick the Right Data Set. Use Help for this Page!
Pathways and ReportsWhich Screen in Reports pull what information?
Intervention Info:
• Charting: all Problem details including problem notes (left hand side of screen)
• Interventions= guides; ifyou want a report to only include thoseitems you checked off or completed, choose “completed”
• Pathway name is available
Pathways and ReportsUsing the Right Filter is a Key to Successful Reports!
• If you don’t filter well, e.g. by Program or Pathway, can get report hundreds of pages long – includes your whole database.
• Interventions (Guides)– get ALL unless you filter to look at just certain key ones you are interested in.
• If you want a report to only include those items you checked off or completed, choose “completed” but don’t include the Field for display
Using the Right Grouping is a Key to Successful Reports!
• Often Best if Group by more than 1 item
Pathways and ReportsIntervention Info with a Target filter but No Intervention Filter:
• If you don’t filter well, e.g. by Interventions (Guides) , can get report hundreds of pages long.
• Interventions – get ALL unless you filter to look at just certain key ones you are interested in.
• If you want a report to only include those items you checked off or completed, choose “completed” but don’t include the Field
• Best if Group by more than 1 item
Intervention Info with 1 Target Filter:
Intervention Info with 1 Intervention Filter:
Intervention Info Grouped By Intervention Filter
Pathway Name but No Client Specific from “notepad”
Pathways and ReportsWhich Screen in Reports pull what information?
Charting Info:
• Charting: all problem details includingProblem notes;
• includes all interventions completed
• no information available forpathways
• includes notes included in the guide “note pads.”
Charting Info: All InterventionsDo get “notepad” info
Charting Info: TGC FilterDo get “notepad” info in parentheses
Custom Tab and ReportsUsing check off boxes?
You cannot create a report where you group by check off box fields- thus can’t get a “count”.
Check off box fields chosen will pull as a “string” in reports.
How to avoid a “string”?Use a Drop Down List Instead
But the drop down option only allows you to choose one option
Immunization OverviewCOMING SOON:
IMMUNIZATION TRACKING INTEGRATED WITH IRIS
Before Using the Immunizations Feature, Setup Must be Done:
Complete the Setup for the 3 items above Working from the Bottom Up.
Two Ways to View and Enter Immunizations:
IRIS will search for a match by name and birthdate:
IF no Match is Found, you have the option to create a new client.
A new screen will come up to add a client as follows:
And a screen to enter immunization detail follows:
Champ Software
PROVIDES A VALID CERTIFICATE WHICH MEETS THE REQUIREMENTS OF THE IOWA ADMINISTRATIVE CODE.
The Power of the PathwayUSING PATHWAYS TO ORGANIZE OMAHA SYSTEM CHARTING
Quick Review
Pathways in Nightingale Notes are built on the Omaha System of documentation
Consists of 3 components:
Problem Scheme
Intervention
Scheme
Rating Scale for
Outcomes (not in
a Pathway)
Creating a Pathway
Basic Steps to build a pathway
1. Identify the client “type” or program name
2. Choose only the problems that are most commonly experienced by that population
3. Add typical interventions related to those problems (Category, Target, Guide)
Creating a Pathway
Take each question and..
1. Name the Problem(s): are you using an umbrella problem or specific problem (remember that more problems does not make better documentation)
2. Dilemma: unique problems allow certain discrete Reporting and Outcomes vs. umbrella problems make faster charting with better flow
3. What Categories are you going to need to use?
4. Decide which Targets do you need to use under those Categories to match your form?
How to take a form style document and make it into a pathway?
Creating a Pathway
Then take each question and Create Guides
Different Styles
1. Guides can be the exact wording from your document, or
2. You can build in your answer, or
3. you can shorten the phrases, or
How to take a form style document and make it into a pathway?
Guides can be delineated to include the positive response and the negative response….
thus documenting the result without much Client Specific Data
Problem Category Target Guide
Neglect Surveillance safety No concerns with neglect
Neglect Surveillance safety Safety concerns identified
Abuse Surveillance safety No concerns with safety
Abuse Surveillance Safety Abuse concerns identified
Vision Surveillance signs/symptoms-physical No concerns reported
Vision Surveillance signs/symptoms-physical Reports blurred vision, double vision, eye pain
Vision Surveillance signs/symptoms-physical Wears corrective lenses/glasses
Vision Surveillance signs/symptoms-physical Does not wear corrective lenses/glasses
Guides can include hints as to the type of documentation expected
Problem Category
Problem Category Target Guide
Respiratory Teaching, Guidance, Counseling
Infection precautions
home isolation; no visitors; hand washing; sputum waste disposal; cover cough; condoms for intercourse
Guides can include hints as to the type of documentation expected – another example
Problem Category Target Guide
Income Surveillance financesMonitor and identify changes in the following: Income, Education, Employment, Transportation, Living/resident status, Other (specify)
Sanitation Surveillance environment
Assess: Airy, bright, chaotic, clean, crowded, cluttered, dark, dirty, messy, noise, safe for baby, smoky, stuffy, toys available, pets, pests, other (specify)
Guides can include hints as to the type of documentation expected – another example
Problem Category Target Guide
Communication with community resources
Case Managementother community resources
Identify resource accessed by family: WIC, food assistance, housing assistance, Medicaid, AEA, medical, dental, education, employment, prenatal classes/childbirth education, parenting classes, other (specify).
Communication with community resources
Case Managementother community resources
Refer family to appropriate community resources and supports as indicated, and authorized by family: WIC, food assistance, housing assistance, Medicaid, AEA, medical, dental, education, employment, prenatal/childbirth classes, parenting classes other (specify). Advocate for family as needed.
Let’s see some ExamplesVery discrete Yes/No guidelinesFP-1000-E; 8/3/15 visit Assessment
Very discrete Procedure guidelinesFP-1000-E; 8/3/15 visit Assessment
Simple Suggestion type Guides (could be Best Practice)TB (4565465); 12/14/12
Suggestion type GuidesTB; 1/18/13
Very complicated suggestion type GuidesHFA (354266); 9/3/15Discrete vs. Umbrella Problem
Very complicated suggestion type GuidesHFA (354266); 9/3/15Discrete vs. Umbrella Problem
Very complicated suggestion type Guides
HFA (354266); 9/3/15Discrete vs. Umbrella Problem
How do I find already existing Pathways?
http://omahasystemmn.org/KBS_care_plans.php - Minnesota Omaha System User Group website (careplans)
http://omahasystemguidelines.org/ - New project by Karen Monsen and other creating evidence-based guidelines
Champ Software has created a document that will allows access to view some shared, available pathways which is housed in Help>Knowledgebase – Search for Pathway ; Click on Pathway Excel Document
Network with other users through our Listserv, User Group meetings or with a neighboring agency
Network with neighboring state agencies to split the task of creating pathways/custom tabs/reports and then share them
How to Request a Pathway
You will need to get permission from the agency and forward that to [email protected] and include:• Name of the pathway group and pathway
name• Where do you want it transferred from and
where do you want it “pasted” to.
Example: I would like the Rabies pathway (Group: Human Hazards) from Vanderburgh’s production database transferred to our training and production databases, they have given permission.
Or, Human Hazards>Rabies, etc.
Custom TabsGOOD, BAD AND THE UGLY
Custom Tabs vs. Pathways:
How to Choose
Custom Tabs….-Custom Tabs give you a choice as to how your data will appear- i.e., drop down, check
off boxes, a date field, text fields etc
Custom Tabs….Custom Tabs are an excellent way toGather Program dataProvide data to an outside entity via Excel or CSV fileSimple “count” of itemsMimic a Flow Sheet or required Form
Pathways…. Pathways allow you to capture data, butlimited to their appearance (don’t look like a Flowsheet)
PathwaysPathways allow you to track outcomes: (K)nowledge, (B)ehavior and (S)tatus
Custom Tabs do not
Summary of ChoicesCustom Tabs/Field Pathways
Track data Track data
More choice on types of fields Less choice of “types of fields”, but can design how data capturedTrack Outcomes
There is a time and place for both…..
E-Signature & Custom Tabs
Custom tabs : Client, Activity, Vitals
CAUTION: Do not include any clinical or other data on
an Activity Tab that requires an electronic signature.
These tabs will not appear on the Visit Report and do not get e-signed.
HOT TIP!Accidently built your custom tab in Client Details and it should be in Activity Details?
You can move your Custom Tab to another Screen by simply editing the Tab name
Are you using Custom Tabs for Charting?
Are you using Custom Tabs for Charting?
Are you using Custom Tabs for Employees?Have you used Custom Tabs in your Employees and
Activity Area?You can use it to capture lots of required into, detailed
results of continuing education and EMERGENCY GOVERNMENT!
So Many Ideas…..
Other ideas… requests… suggestions?
Join us this afternoon for one of two work sessions on billing or clinical documentation and processes
Participate in the Champ Iowa User Group Meetings.
Suggest Topical Webinars. If you cannot participate, view at your leisure.
So Many Ideas…..
Special Thanks for the assistance on this presentation to
Bev Larson, MPH, RN, CPHQ
Norah Savard, RN, PHN
Training & Implementation Coordinators
Don’t forget for help:
Knowledge Base under Help
Thank you for your
participation and for all you
do for your agency and community!
