This document should be used as a checklist and reference for Agency Nurses working in our facilities. 


Printable Version available for Download


PCC Training /PCC Overview for Agency Nurses

☐       Dashboard

  • Monitor POC and insure completion prior to end of shift
  • Monitor eMar/eTar and insure completion prior to end of shift
  • Monitor and address alerts: Stop & Watch, Order Alerts & Clinical Alerts 
  • Monitor and follow up on Labs (if integrated)

 

☐       UDA Portal and User Defined Assessments (UDA’s)

Select your Unit, change “Show Assessments due in next” to 0 days, complete all UDA’s due for you. Be sure to click the filter box to the far left to see all assessments scheduled. 

Remember just because it is overdue, does not mean it is not for you. Assessments are scheduled and the UDA portal will only show the most overdue note. You may need to change the date and time to current to write your note so that you are in compliance and following standards of practice/policy and procedure. We do not use New on the Progress Tab to write nursing notes as the UDA will create our Notes for us when they are completed.

Tips for knowing what UDAs to use:

  • 7 LN: Comprehensive Carepath : New Admissions/Readmission/LTC MDS  Note- Triggers once a day for first 7 days of admission. Continue once a day on skilled residents or if ltc resident then once daily during their MDS lookback period
  • LN: Weekly Skin Monitoring: Due weekly on same day and shift. If overdue, please check the schedule and complete 
  • 8 LN: Charting by Exception: Is for charting by exception, if another UDA is scheduled that matches the reason for charting, then DO NOT substitute with this UDA. This is to be used when there is no other UDA that matches the reason for charting. 
  • LN: Physical functioning monitoring – Is your post fall note- Will trigger q shift x 3 days. Know who has fallen, information can be obtained from report
  • 1 LN: Initial event Documentation- Is the note you will open for initial events (Anything you would fill out an incident report for) When filling this out, be prepared to do additional documentation, depending on the type of incident, other assessments may trigger. 
  • 2LN: New Order Note: Is the note you will choose for new orders, It is important to utilize this as it will trigger Antibiotic notes, Coumadin flow sheets etc. depending on what you pick 
  • eInteract Change in Condition evaluation: required for Change of Condition for resident will create your SBAR eInteract Transfer Form will trigger with Quick ADT action of Transfer out. Must be completed for Hospital Transfer. 
  • Pay attention and know who is on antibiotics, has recent psychoactive medication changes etc. Documentation will be triggered.

This is not the exclusive list of documentation that may be required of you but a brief overview. Remember to ask questions if you find yourself needing assistance.

☐       Orders Portal

  • Check Orders Portal for orders left in queue and complete if created by you
  • Check Orders Pending Confirmation and confirm orders entered by you and by providers for resident’s assigned to you. 

☐       Labs/Radiology (if Integrated w/ PCC)

  • Labs/Radiology may be viewed on your dashboard easier to see complete lab listings from the lab portal
  • Ensure all labs/radiology results are received and reported prn to Physician Services 
  • Match any unmatched labs 

☐       Labs/Radiology (if NOT Integrated w/ PCC)

  • Review lab/radiology report from PCC and requisition log from lab/radiology to make sure results scheduled for that day are received
  • Review internal processes for lab/radiology results and documentation

 

 

 

 

Employee Name & Title: __________________________________________________________                          

Employee Signature:   _____________________________________________________________               Date: ____________________

Trainer Name and Title: __________________________________________________________

Trainer Signature: ________________________________________________________________           Date: ____________________