Nurse Workflow.docx

NURSES WORKFLOW Nurse will be notified by the Therapist that client is ready for Nurse Assessment. GoHealth Client and the Nurse goes to Triage and will start assessments. GoHealth Admission Order Physician's Medication Orders Box: Medication name, Dosage, Reason for Taking Admis...

NURSES WORKFLOW Nurse will be notified by the Therapist that client is ready for Nurse Assessment. GoHealth Client and the Nurse goes to Triage and will start assessments. GoHealth Admission Order Physician's Medication Orders Box: Medication name, Dosage, Reason for Taking Admission History Nurse Assessment In Intake Comments: Give brief nursing assessment ex: 14yo make A/O agreeable and polite to all staff, answered questions normal gate, VS WNL, Lungs clear heart sounds strong and normal skin issues (scars, cuts…) made eye contact, clean, well groomed, dressed appropriately for the season. Enter medicines and allergies into Rcopia (if needed) Click on the Medical tab, then Nurses Assessment to access “launch “Rcopia” Scroll down until you see the “Medications” heading. Click on “Launch Rcopia” Be specific. Do not enter abbreviation. Use Brand Name or Generic Name written on medicine bottle. The three lines in the upper left corner directs you to enter medication or allergies AIMS Dyskinesia- only if client is experiencing psychosis Only if client is experiencing psychosis or has medications that are known to have side effects r/t Tardive Dyskinesia Client Admission Type The admission type will be changed from Outpatient to URC if the client is going to be discharged to inpatient. Clients discharged to higher level of care will need to see the Provider. Client’s discharged to lower level of care may see the Provider if they or the school request. Otherwise, we will not have client’s discharged to lower level of care see the Provider. The Nurse and Life Skills Coach will be tasked with contacting the on-call Doctor/Med. Provider for assessment. The chart will be turned green if the chart has been moved from outpatient to URC (inpatient/residential). The client will now need to see the Doctor/Med. Provider on the schedule for today. In the Client’s GoHealth profile, go to the URC drop down, choose Admission tab, and click on Client Data Center. See below. At the top of the client data center, it will say if the client’s admission type is URC. If not switched for higher level of care clients, have the Life Skills Coach, Office Specialist, Data Specialist or Therapist make the change. Microsoft Teams – Calling Provider (if needed) Have client connect with prescriber via video call.   Follow the steps below. Use the Provider Information form, found in the 2nd drawer of the nurse’s desk, to determine who to call. Agency Nurses will need the Life Skills coach to contact the provider. During the holiday season, check your outlook for an email on provider scheduling.   Log into your account on the computer in the Therapist 1 office, office nearest to the Nurse station, computer and set it in front of client and parent. Once logged in, click on “CRS Sharepoint” icon located on the homepage of your laptop. You should see the box displayed below. Log in with your work email.           Click on the 9 dots icon in the top left of the screen. Click on “Teams.” Click on Chat Go to the YES Teams chat. Send a message saying we have a client who is ready to see “on-call providers name.” Search the providers name if not displaced in your chat list. Click on the providers name once it pops up in the search. Once the provider is ready for the call, click on the little video camera icon in the image below. Make sure the lens video camera lens on the front of the camera is slid open. Leave the client (and possibly their parent) alone with the provider. If client is staying overnight: Collect and count any medications brought in. Fill out Admit/Discharge medication form. Parent will need to sign for the admittance of the medication AND when Client is discharged. Located in the file folder drawer at the nurse desk. Search clients with LSC or other staff member Client gives personal belongings (phone, shoes with laces, wallet, purses, jewelry, piercings, etc.) to guardian. Client goes with Nurse and another staff member to be searched. Paper form is used. Paper form is put in client chart. If there is a shift change while with a client: Progress Note Provide data specialist with client packet containing referral sheet, demographics sheet, body search form and nurse shift report. Include all other Client information.