Findings that are OEL (Outside Expected Limits) require supportive documentation (e.g. Tachycardia). This should be used for some recognized issue but not deemed a problem. This likely has no targeted interventions for the issue. This usually indicates something you will to “continue monitor.” Identified Care Classification Category (Saba Model) problems require supportive documentation within the assessment section. Typically you will not choose WNL, WEL, or OEL and a Saba Problem. The exception to that rule is the need to describe or identify some baseline known condition (ex. DM type 1) but the patient may be here for acute DKA. Communicating that the patient is a known diabetic and that he now has an acute exacerbation of that condition is important in telling the patient story. Key Discussion Points From your colored card, look at the line YOUR PATIENT FOR HED. You can also refer to the page with the armband. Select your patient in Care Organizer and clicking the HED button which opens the tab as a default. “PLAN” Click from left column to expand all of the available charting options “Show All” of the vitals section of the patient chart. Click in the charting field to show all the components of the vital signs “Show All” I/O fields. If no charting fields are present, click the Chart button Time can be adjusted back to time charted but not forward using the numbers on the keypad or the Move across fields using the tab button Change time to 30 minutes ago. Enter the following information in the PAIN Assessment section: pain of 6 on numeric scale Chart Document pain location in Pain site (click other and annotate rib). There is a 240 character limit. Click sharp and stabbing for Pain description Chart Pain goal is 3
Findings that are OEL (Outside Expected Limits) require supportive documentation (e.g. Tachycardia). This should be used for some recognized issue but not deemed a problem. This likely has no targeted interventions for the issue. This usually indicates something you will “continue to monitor.” Identified Care Classification Category (Saba Model) problems require supportive documentation within the assessment section. Typically you will not choose WNL, WEL, or OEL and a Saba Problem. The exception to that rule is the need to describe or identify some baseline known condition (ex. DM type 1) but the patient may be here for acute DKA. Communicating that the patient is a known diabetic and that he now has an acute exacerbation of that condition is important in telling the patient story. Key Discussion Points From your colored card, look at the line YOUR PATIENT FOR HED. You can also refer to the page with the armband. Select your patient in Care Organizer and clicking the HED button which opens the “PLAN” tab as a default. Click “Show All” from left column to expand all of the available charting options of the vitals section of the patient chart. Click “Show All” in the charting field to show all the components of the vital signs I/O fields. If no charting fields are present, click the Chart button Time can be adjusted back to time charted but not forward using the numbers on the keypad or the Move across fields using the tab button Change time to 30 minutes ago. Enter the following information in the PAIN Assessment section: Chart pain of 6 on numeric scale Document pain location in Pain site (click other and annotate rib). There is a 240 character limit. Click sharp and stabbing for Pain description Chart Pain goal is 3
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