1 2 SuperUser Documentation Auditing tool 1. HED opens to the PLAN tab a)Verify there are 1-3 Priority Problems identified (PP’s are denoted in red) b)Verify there are corresponding short term goals for each Priority Problem c)All goals are expected to be addressed in the Response to Care/ Recommendations field 2 PP’s 2 Goals 2. The ASSESSMENT tab (the bulk of the doc audit) a)Menu bar – All fields assessed on admission; only CAPITALIZED terms required for head to toe daily assessment. Otherwise non-capitalized terms documented when applicable 3.What to look for in the ASSESSMENT tab from top to bottom a)Pain score present? b)Go through all the assessment sections a)WEL, OEL, or Problems all require supporting documentation OR ANOTHER WAY TO THINK OF IT everything other than WNL requires supportive documentation. c)Supportive documentation in the form of: a)Annotations b)Dropdown menu items c)Discreet data such as Vital signs & Blood glucose values See other side for top to bottom example

Pain score??/ also the field used for reassessment scores WNL = No need for supportive data WEL, OEL, & Problems = Requires supportive data in the form of annotations, dropdown menu data, discreet data Tip: As you go through the chart, verify that all fields not addressed are all non-CAPS The ASSESSMENT tab from top to bottom 4.EDUCATION tab a)Care Contacts b)Education ALL DOC tab The ALL DOC tab has every field in the new build. On occasion you will not be able to find a specific field to use. The ADD function (click chart -> add) allows the user to search for a desired field. See the example to the right: leech therapy; from the example we can see leech therapy is located in the SKIN All section. Continue to click Find Next to see all available matches Hover function – Take time to hover over fields to get more information. Hovering reveals: How often to document Considerations for this documentation field **Occasionally WEL, OEL, & Problems do not require supportive data. Check with your CAPS support person in this situation**

MRN/Rm # Nurse Initials Content to Follow up with nurse/CommentsDocum. Complete Pt #1 Plan Tab Assess All Docs Educ Notes Pt #2 Plan Tab Assess All Docs Educ Notes

MRN/Rm # Nurse Initials Content to Follow up with nurse/CommentsDocum. Complete Pt #3 Plan Tab Assess All Docs Educ Notes Pt #4 Plan Tab Assess All Docs Educ Notes