Documentation, Exams of Nursing

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Center For Human Phenomic Science (CHPS)

Center for Human

Phenomic Science

University of Pennsylvania

Health System

CHPS

SOP 07

Standard

Operating

Procedure

Documentation

Page 1 of 3 PURPOSE: To provide documentation that is pertinent, accurate, consistent, standardized, and relevant. SCOPE: CHPS staff and Clinical Study Teams PROCEDURE:

1. CHPS staff follows hospital policy regarding Documentation including:
   • General Documentation: HUP Policy 4A- 02 - 01
2. Nurses may need to document on two separate sources. The source documents are the nursing worksheet for the clinical study team and EPIC.
3. EPIC documentation a. The following are required to be documented in EPIC: a. All vital signs b. Any invasive procedures including blood draws and IV placement c. The number of IV insertion attempts d. Medication checks e. Medication administration including Infusion start and stop times d. Communication with study team regarding abnormal vital signs, or other changes in clinical status e. Progress note on every patient. b. All studies use Beacon/EPIC orders for medication ordering so that nurses can document medication administration properly in EPIC.

Center For Human Phenomic Science (CHPS)

Center for Human

Phenomic Science

University of Pennsylvania

Health System

CHPS

SOP 0 7

Standard

Operating

Procedure

Documentation

Page 2 of 3 c. All investigational medications need two nurses to Med Check in EPIC, whether or not the system prompts for a second nurse check. d. Infusion administration requires start and end times documentation in EPIC. e. The time of medication documentation in EPIC must match the time of administration on the worksheet. f. Blood draw only appointments require LDA in EPIC, Progress Note, and CHPS billing worksheet.

4. Nursing Worksheets a. It is both the CHPS and Clinical Study Team’s responsibility to make sure all parts of the nursing worksheet are complete. It is best practice for both parties to review the nursing worksheet to ensure documentation is complete at the end of visit. This nursing worksheet is retained by the study team. i. All blank spaces must be completed on the nursing worksheets. This includes initials, times, signatures and any other information needed for blank spaces. ii. All CHPS staff that participated in the participant’s care must sign the worksheet (except medication check in EPIC). iii. On the worksheet signature table, if all CHPS staff have signed and there are empty lines, the CHPS RN must write “N/A” on those blank lines. CHPS STAFF SIGNATURE PRINTED NAME SIGNATURE INITIALS DATE Jane Doe (^) Jane Doe JD 1/5/ NA NA NA NA NA NA NA NA

Center For Human Phenomic Science (CHPS)