Quick Reference Guide. for Unit Secretaries and OB Unit Secretaries

Transcription

1 Quick Reference Guide

2 Quick Reference Replace Guide w Table of Contents Introduction to SCM 4 4 Log on to SCM 4 Log off SCM 4 View the Patient Chart 4 4 Find a Patient 5 View Patient Allergies 5 View Orders 5 View Results 5 View Documents 6 View the Clinical Summary 6 Print Reports 6 6 Print Reports with Default Settings 7 Print Reports with Custom Settings 7 Create Criteria-based Lists 7 7 Create a Criteria-based List by Location 8 Create a Criteria-based List by Orders 8 Modify a Criteria-based List 9 Create Personal Lists 9 9 Create a Personal List 9 Remove a Patient from a Personal List 10 Add a Patient to a Personal List 10 Add a Patient using the Find Patient Feature 10 Page 2

3 /Branding Quick Reference Guide Complete Quick Registration Complete a Quick Registration 11 Manage Significant Events Add Significant Events 12 Edit Significant Events 12 Discontinue Significant Events 12 Add Charges Add Retrospective Charges through Order Entry 13 Complete Nursing Discharge Instructions Document and Review Discharge Instructions 14 Complete the Adult Discharge Nursing Note 14 Send Messages (SHM) View Messages in iview 15 View Messages in SHM 16 Send Messages in SHM 16 Create a Mailbox 16 Create a Group 17 Send a Message to a Group 17 Add a Proxy 17 Page 3

4 Quick Reference Replace Guide w Introduction to SCM Sunrise Clinical Manager has many benefits including viewing real-time patient data, providing better communication between clinicians, eliminating errors, and many more. iconnect icon Login button Shutdown icon Log on to SCM From your computer desktop: 1. Double-click the iconnect icon. 2. Type your user name in the User Name field. 3. Type your password in the Password field. 4. Click the Login button. Log off SCM From SCM: 1. Click the Shut Down icon. View the Patient Chart Sunrise Clinical Manager provides clinicians easy access to patient information. Find Patient button Allergies Summary button Red Flag icon Page 4

5 /Branding Quick Reference Guide Display View button Display Format button Reset button View button Find a Patient From the Patient List: 1. Click the Find Patient button. 2. Search for the patient by any of the identifying information; then click the Search button. Note: Best practice is to search by MRN. 3. Select the patient. 4. Click the Show Visits button. Note: You can also create a visit for the patient by clicking the Create Visit button. 5. Select the visit you want to view. 6. Click the OK button. View Patient Allergies With a patient selected: 1. Click the Allergies Summary button. 2. To view details of a particular allergy, select the allergy; then click the Details button. View Orders With a patient selected: 1. Click the Orders tab. 2. Use the Options Panel to filter the orders you want to view. 3. To view details of the order, double-click the order. View Results With a patient selected: 1. Click the Results tab. 2. Use the Options Panel to filter the results how you want to view them. Page 5

6 Quick Reference Replace Guide w Note: New results are indicated by a red flag icon. 3. To view details of the result, double-click the result. 4. To return to the summary view, click the Display View button. 5. Select Summary. 6. To see a trend for the results, click the results you want to trend. Note: You can select multiple results by dragging your mouse across selected results, or use the Control key to select multiple results. 7. Select Trend in the Options Panel. 8. To view trend and graph for selected results, select Trend and Graph in the Options Panel. View Documents With a patient selected: 1. Click the Documents tab. 2. Use the Options Panel to filter the documents how you want to view them. 3. To view a document, select the document; then click the View button. 4. Select Document Details. Note: To modify the document, click the Modify tab. To view the status of the document, click the Status tab. 5. To close the document, click the X Close button. View the Clinical Summary With a patient selected: 1. Click the Clinical Summary tab. Print Reports You can view and print various reports on demand from within Sunrise Clinical Manager. Print Reports button Print icon Export icon Page 6

7 /Branding Quick Reference Guide Print Reports with Default Settings 1. Click the Print Reports button. 2. Click the Report Category drop-down arrow. 3. Select the appropriate report category. 4. Select the report you want to print. 5. Click the Preview button. 6. To print the report, click the Print icon. Note: You can also export the report by clicking the Export button. 7. Make sure the correct printer is selected; then click the OK button. 8. Your report displays. To close the report, click the X Close button. Print Reports with Custom Settings 1. Click the Print Reports button. 2. Click the Report Category drop-down arrow. 3. Select the appropriate report category. 4. Select the report you want to print. 5. Click the Preview button. 6. The Report Submission Information window displays. Add the appropriate filters for your report; then click the OK button. 7. To print the report, click the Print icon. Note: You can also export the report by clicking the Export button. 8. Make sure the correct printer is selected; then click the OK button. 9. Your report displays. To close the report, click the X Close button. Create Criteria-based Lists An important part of patient safety is to maintain an accurate record of patient information and effectively manage patients. Many clinicians will get pre-built lists; however, it is important to create criteria-based lists by categories such as location and orders, as well as modify criteria-based lists to achieve accuracy and efficiency. New Visit List button Add button Page 7

8 Quick Reference Replace Guide w Modify VIsit List button Rename button Create a Criteria-based List by Location From the Sunrise Patient List tab: 1. Click the New Visit List button. 2. Click the Location tab. 3. Click the Include patients at selected locations only radio button. Note: There are also radio buttons that allow you to include patients at any location and at logon location only. 4. Click the Flagler Hospital plus icon. A list of departments within Flagler Hospital displays. 5. Select the first location option you want to include in the list. Note: Expand the various departments by clicking the + icon in order to view additional locations within the department. 6. Press the Control key and select the next location option you are assigned to. 7. Click the Add button. Note: Your locations should display in the Selected Locations pane. To remove a selected location, select the location to be removed and click the Remove button. 8. Click the OK button. Enter a name for your list; then click the OK button. Create a Criteria-based List by Orders From the Sunrise Patient List tab: 1. Click the New Visit List button. 2. Click the Orders tab. 3. Click the Check this box if you want to create a list of patients that only have orders as specified below check box. 4. Click the Add New button. The Add New Order Selection Filter window displays. 5. Name the new filter; then locate and select the appropriate filter from the Orders list. 6. Click the Add button. 7. Save the selection; then click the OK button. 8. Click the Order Selection Filter drop-down arrow. 9. Select the desired order selection filter. 10. Click the OK button. 11. Click the OK button to acknowledge the need to add a provider role, a provider, a location, or an advanced visit list definition. Page 8

9 /Branding Quick Reference Guide 12. Add one of the other required elements. 13. Click the OK button. 14. Name the new list; then click the OK button. Modify a Criteria-based List From the Sunrise Patient List tab, displaying the appropriate criteria-based list: 1. Click the Modify Visit List button. 2. Make any changes to the criteria. Note: To just change the name of the list, you do not need to make any changes to the criteria. 3. Click the OK button. 4. Click the Rename button. Create Personal Lists An important part of patient safety is to accurately and efficiently track patients throughout their stay. Creating and modifying personal lists allows you to view your assigned patients only, and therefore, better focus on their needs. Save Selected Patients... button Remove Selected Visits button Find Patient button Show Visits button Save To List button Create a Personal List From the Sunrise Clinical Manager, Patient List tab: 1. Select the patients you want on your personal list. Note: Multiple patients can be selected by clicking and dragging the patients in order, or by pressing the Control key and selecting the desired patients. To deselect a single patient, click their name while holding the Control key. 2. Click the Save Selected Patients button. Page 9

10 Quick Reference Replace Guide w 3. Click the New List Name field. 4. Enter the desired list name; then click the OK button. 5. Add additional patients to the list as needed. Remove a Patient from a Personal List From the personal list: 1. Select the patient; then click the Remove Selected Visits button. Note: Do not click the Delete Current List or the Delete Visit List button; these buttons delete lists, not visits. If a patient is deleted by mistake, they must be re-added to the list. Add a Patient to a Personal List From the Patients at Logon Location list: 1. Click the Current List drop-down arrow. 2. Select Patients at Logon Location. 3. Locate and select the desired patient s name. 4. Click the Save Selected Patients button. The Save Selected Patients window displays. Note: Select the Add radio button to add a selected patient. Select the Replace radio button to replace all the patients currently on the list. 5. Click the OK button. The desired patient is added to the personal list. Add a Patient using the Find Patient Feature 1. Click the Find Patient button. 2. Select MRN from the ID Type drop-down menu. 3. Type the patient s MRN; then click the Search button. 4. Select the desired patient. 5. Click the Show Visits button and select the correct visit. 6. Click the Save to List button. 7. Click the OK button. Note: Make sure that the Add Patient to Selected List radio button is selected, and that the correct personal list is highlighted. Note: The second option for adding a transfer patient consists of following the same steps; however, instead of using the Save to List button, the patient is added by clicking the Save Selected Patients button from the Temporary List. Again, the Add Patient to Select List radio button must be selected, and the My Assignments list must be highlighted. Page 10

11 /Branding Quick Reference Guide Complete Quick Registration Express registration is currently done in the Emergency Room and OB. This was developed to get a patient in the system quickly. This is helpful so that a minimal amount of information can be set up for medication and other services to be administered to patients. All patients who present to the Emergency Department will be quick registered. All patients who present to OB in Triage will be quick registered. Find Patient icon Add Patient/Visit button Create New Visit button Complete a Quick Registration From the Enterprise Registration screen: 1. Click the Find Patient icon. 2. Search for the patient with as much information as possible. 3. Click the Search button. Note: If the patient is not in the system, click the Add Patient/Visit button. If the patient is in the system, click the Create New Visit button. 4. Click the Express Registration check box. 5. Click the Visit Type drop-down arrow. 6. Select the appropriate visit type. 7. Click the OK button. 8. Enter all of the information you have for the patient. Note: Fields with red asterisks indicate mandatory fields that must be completed. 9. When all mandatory fields are completed, click the OK button. Manage Significant Events An important part of patient safety is to maintain and manage accurate records of a patient s significant events. Clinical Summary tab Page 11

12 Quick Reference Replace Guide w Patient Info tab Apply button Discontinue button Add Significant Events With a patient selected: 1. Click the Clinical Summary or My View tab. Note: Significant events can also be entered through Structured Notes and from the Patient Info tab. 2. Right-click in the Significant Events pane. 3. Select Add New. 4. Click the Type drop-down arrow. 5. Select the type of interest. 6. Click the Event drop-down arrow. 7. Select the event of interest. Note: Add your own event to the selection list by clicking the Event field and documenting the selection; then click the Apply button. 8. Document more information about the event in the Description field. 9. Click the OK button to submit the events. Edit Significant Events With a patient selected: 1. Click the Patient Info tab. Note: Events can also be edited by right-clicking the event in the Clinical Summary tab. 2. Select Significant Events in the Summary Views list. 3. Double-click the event to modify. 4. Make the appropriate edits; then click the OK button. Discontinue Significant Events From the Patient Info tab: 1. Select Significant Events in the Summary Views list. 2. Double-click the event to discontinue. 3. Click the Discontinue button. 4. Click the Show Inactive check box to view inactive events. Page 12

13 /Branding Quick Reference Guide Add Charges Many of the charges for a patient s stay are included in a patient s room and board. Some charges, however, must be added manually to the patient s chart. This can be done in one of three ways: through order entry, on task completion, or on order completion. For roles and departments responsible for adding charges, a Charge Reconciliation Report is generated each day for the previous day s charges. This report lists all of the charges that were put into SCM, and compares or reconciles them to all of the charges that posted on the Patient Financial Manager side. This report helps to identify tasks or orders that may not have been completed and did not generate charges. Enter Order icon Worklist Manager button Add Retrospective Charges through Order Entry From the patient s chart: 1. Click the Enter Order icon in the patient banner. 2. The Problems Manager window displays. Associate the problem to the order. 3. Click the Save to Order button. 4. The Order Entry Worksheet window displays. To add a charge, click the Charges + icon. 5. Select the appropriate charge-related order set. 6. Click the Add button. 7. The Charges Order Set Form window displays. Select as many charges as needed by clicking the appropriate check box(es). 8. Add the date of service for all charges. Click the Date of Service field. 9. Click the Date of Service calendar icon. 10. Click the correct date. 11. Press Enter to save the changes. 12. When you are finished adding all charges; click the OK button. 13. Submit the order; click the Submit Order(s) for patient button. Page 13

14 Complete Nursing Discharge Instructions Quick Reference Replace Guide w An important part of patient safety is to maintain accurate discharge procedures. Once a physician enters his discharge order sets and completes the patient instructions and follow-up, nurses can document and review discharge instructions with their patients, as well as complete their Discharge Nursing Notes. Enter Document button T button C button Open button Documents tab Document and Review Discharge Instructions With the patient selected: 1. Click the Enter Document button. 2. Locate and select the appropriate document; then click the Open button. 3. Select each section to review with the patient. 4. Select Signatures to mark whose signatures are required on the printed discharge instructions. 5. Click the Signature/Date check boxes for both the nurse and the patient. 6. Document the signature dates for both signatures. Note: The C button can be used to access the calendar function, or the T button can be used to populate the current day s date. 7. Click the Preview tab to review the patient s discharge information. 8. Click the Save button. 9. Enter your password; then click the OK button. Complete the Adult Discharge Nursing Note From the Document Entry Worksheet window: 1. Locate and select the appropriate document; then click the Open button. 2. Complete the note using the appropriate radio buttons and check boxes. 3. Click the Save button. 4. Enter your password; then click the OK button. Page 14

15 /Branding Quick Reference Guide Send Messages (SHM) An important part of patient safety is to communicate clearly regarding a patient s health and visit. Sunrise Secure Health Messaging (SHM) provides communication between care providers. With Secure Health Messaging, you can exchange general messages about patients to other providers participating in that patient s care. My View tab Message History button Secure Messaging button Reply icon Reply All icon Delete Message icon Forward Message icon Print Message icon Refresh Message List icon Reading Pane icon Move To Folder button Magnifying Glass icon Add to List button Send button Cancel button Attach to selected visit button Add Proxy button View Messages in iview 1. Click the My View tab. Note: You can view messages from the My View tab or by clicking the Secure Messaging button. 2. Select message of interest. Page 15

16 Quick Reference Replace Guide w 3. Right-click message of interest. 4. Select View SHM Message. 5. Click the Message History button to view the history of the message. 6. Click the Close button to close the message history. 7. Click the Close button to close the message. Note: To view sent or deleted messages in SHM, click the SHM drop-down arrow and select the time of messages to view. View Messages in SHM 1. Click the Secure Messaging button. Note: You can filter what displays by using the Show menu. 2. Select message of interest. 3. Click the Close button to close the message. Send Messages in SHM From Secure Health Messaging: 1. Click Compose. 2. Select General Message. 3. Click the Magnifying Glass icon to select recipient. 4. Search for the recipient; then click the Search button. 5. Click the appropriate recipient check box in the Available section. 6. Click the Add to List button. 7. Click the OK button. 8. Type a subject in the Subject field; then press the Tab key. 9. Type message; then click the Send button. 10. Search for the patient in order to attach it to the patient record. 11. Click the appropriate radio button for which to search: favorites, my patients, or all patients. 12. Click the Search button. 13. Select the patient whose record you want to attach the message to. 14. Click the Attach to selected visit button. Create a Mailbox From Secure Health Messaging: 1. Click Tools. 2. Select Mailboxes. 3. Type the mailbox name in the Mailbox name field; then click the Add button. Page 16

17 /Branding Quick Reference Guide Create a Group From Secure Health Messaging: 1. Click Tools. 2. Select Groups. 3. Type the group name in the Group Name field; then click the Add button. 4. Search for providers to add to the group; then click the Search button. 5. Click the appropriate recipient check box in the Available section. 6. Click the Add to List button. Note: Add additional group members by performing a new search and following the same steps for selecting recipients. 7. Click the OK button. Send a Message to a Group From Secure Health Messaging: 1. Click Compose. 2. Select General Message. 3. Click the Magnifying Glass icon to select recipient. 4. Click Group. 5. Type the group name in the Group Name field; then click the Search button. 6. Click the appropriate group check box in the Available section. 7. Click the Add to List button. 8. Click the OK button. 9. Draft the message and then send it, following the same steps for Send Messages in SHM. Add a Proxy From Secure Health Messaging: 1. Click Tools. 2. Select Proxies. 3. Select the message type. 4. Click the Add Proxy button. 5. Search for the person you want to be the proxy; then click the Search button. 6. Click the appropriate proxy check box in the Available section. 7. Click the Add to List button. 8. Click the OK button. Page 17

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