Interactive View Instructions

Transcription

1 Interactive View Instructions Definition... 2 Navigator... 2 IView Tool Bar... 3 View Pane... 3 Charting... 4 Charting IView Tasks... 4 Back Charting... 6 Correcting Charting Errors... 6 Copy Documentation... 7 Charting Dynamic Groups... 8 To Unchart a Dynamic Group... 9 To Inactivate and Activate a Dynamic Group... 9 Customizing Setting User Preferences Filter Search Criteria Bar Timescale I&O Band NA I&O Charting IV Volumes Charting Medication Drip Rates Charting Frequent IV Medication Drip Changes Discontinued IVs Page 1 of 17

2 Definition Interactive View (hereafter referred to as IView) is a tab in PowerChart that allows the user to chart and organize patient data in a meaningful manner. There are 3 main sections: Navigator, View Pane and Filter and Seeker. Filter and Navigator View Pane Navigator The Navigator is made up of a number of bands and sections. Click the band to open to the defaulted view. Click the sections to open a specific section of the band. Indicates data is charted. Indicates a critical value. The sections are color-coded. Bands Sections Light blue means the section will default open when the band is clicked. Dark blue indicates the section displaying at the top of the flowsheet. White indicates sections that are not defaulted open. Click the section to open. Page 2 of 17

3 IView Tool Bar Collapses the Navigator allowing more room for the View Pane. Splits the window to view data from 2 different bands. Hides or shows empty rows and columns. Signs charting. Cancels charting. Associates monitor in PowerChart. Used in the critical care units only. Creates a label for a new Dynamic group Actions- Duplicates entered data or clears unsigned data View Pane The view pane is used for charting and viewing patient data. The flowsheet view is determined by location and/or user position. The display can be customized to fit the patient. View Pane Tool Bar Customizes the flowsheet. Inserts columns for back charting. Changes start time of I&O totals. Indicates a calculated result. Hover to view contributors. Page 3 of 17

4 Charting 1. Double-click the time cell to activate charting in all the sections open on the flowsheet. Double-click the section header to activate just one section To chart in one cell only: right-click and select Add Result. 2. Use the keyboard instead of the mouse for easier and quicker charting. Press the Tab key until you reach the correct cell and enter data. Use the Arrow key to select an option from a drop-down menu. Use the Space bar to select options with a check box. Or use the Tab key with the mouse. 3. To enter a comment, right-click on cell and select Add Comment. 4. Review charting. 5. Click the Sign icon. Double-click the time cell to activate all the sections. Double-click the section header (dark blue or gray) to activate one section. Charting IView Tasks A PAL task can open IView for charting 1. Right-click the task and select Chart Details. 2. A new band is created Activity View. 3. The section will be activated and ready for charting. 4. Once the task has been charted, the band does not display when chart reopened. Page 4 of 17

5 Click this icon to change the documentation time for a task. Because PAL tasks default to the time that the task is due, you may need to change the time of service for the task. To change the time of service on a PAL task, click the paper and clock icon (above). Select the task and insert the correct time of service. A new column will be created with the desired time of service. Page 5 of 17

6 Back Charting 1. Click the Insert Column icon. 2. Change Column Date/Time opens. 3. Enter correct time. 4. Chart patient information. 5. Click the Sign icon. Correcting Charting Errors If patient information was charted by a form through Ad Hoc Charting or PAL, go to Forms to make corrections. 1. Right-click the data to be corrected. 2. Select Modify, Unchart, Change Date/Time or Add Comment. 3. Unchart is used for duplicate charting or charting on the wrong visit or patient. Modify 1. Select Modify. 2. Enter correct information in the cell. 3. Click the Sign icon. Unchart 1. Select Unchart. 2. Click the yellow Reason field or the Reason field in the lower window and select an option. 3. Click Sign. Select a reason from either field. Reason is required as indicated by the yellow field and the dithered Sign button. Page 6 of 17

7 Change Date/Time 1. Select Change Date/Time. 2. Enter correct date/time. 3. Enter a comment. 4. Click the Sign icon. Add Comment Comments can be added prior to signing and after signing. 1. Select Add Comment. 2. Enter data. 3. Click OK. Note: Uncharting and Change Date/Time allows multiple cells to be changed simultaneously. Depress the Ctrl key while clicking the cells to be changed. Right-click on any one of the cells and select an option. Copy Documentation 1. Find the time header for the documentation that you want to copy. NOTE: Do Not highlight a column with another discipline s data. 2. Click blue (label) section header o Column becomes highlighted 3. Click Actions icon on tool bar 4. Click Duplicate Results 5. Enter Date/Time of documentation and click OK 6. Results populate new column. 7. Click in cell to make modifications as needed. 8. SIGN Page 7 of 17

8 Charting Dynamic Groups 1. Select the desired band 2. Click the Add a Dynamic Group icon to create a label if not present 3. Define the label by selecting the appropriate options Yellow indicates the field is required Scroll to view all choices 4. Verify Label is correct 5. Click OK to close the window 6. The label is displayed inside brackets until it is signed. 7. Click Sign Page 8 of 17

9 To Unchart a Dynamic Group Once the label is signed it cannot be modified, however it can be uncharted. All results within that subsection must be uncharted from each cell. 1. Make sure all data has been uncharted from each cell 2. Right-click the dynamic group label 3. Click Unchart 4. Select a reason from the Unchart window 5. SIGN 6. The uncharted label will display as In Error and the section will be dithered. 7. Once data is Uncharted, the subsection cannot be re-activated. The user needs to create a new label. To Inactivate and Activate a Dynamic Group Always chart discontinue and then inactivate a dynamic group subsection when it is no longer needed, such as when a drain or tube is removed or an IV is discontinued. When a label is incorrect and multiple staff have already documented on it: Right-click in the Activity field Click Inactivate-site clarification Sign Follow steps below to Inactivate incorrect label. To Inactivate a subsection Right-click label to be inactivated. Click Inactivate 1. Inactivating a group will dither entire section Page 9 of 17

10 To reactivate a subsection that has been accidently inactivated: 1. Right-click label 2. Click Activate Customizing You can customize the display for the patient that affects all clinicians who chart. The display can also be altered for the current charting session only. (Settings return to the default when the chart is closed.) To customize for the patient (changes retained after chart is closed or refreshed): 1. Click the Customize View Icon. 2. Select and de-select the items by clicking the check boxes. 3. Click OK. Click the Default Open box to display the section on the flowsheet when IView is opened. Checking On View puts the section on the Navigator and leaves it closed on the flowsheet. Shaded boxes cannot be deselected. Use this field if looking for a specific item. It s easier to find a section if you click Collapse All. When the section with data has been deselected, the Navigator will have a checkmark indicating data is present. Click the section on the Navigator to view. To customize on the flowsheet : 1. Right click on section or item. 2. Select option. Collapse: Collapses section for current session. Close: Removes section from View Pane and leaves section name on Navigator for current session. Remove: Removes section from View Pane and Navigator for all users and retains the change Page 10 of 17

11 after closing the chart or refreshing. To Split the window to view data from 2 different bands: 1. Click the Split Window icon. 2. Click within the 2 nd window to highlight. 3. Click the 2 nd band. 4. Click the section to display in the 2 nd window. 5. Click to remove the split. To hide empty rows/columns 1. Click the Show Empty Columns/Rows icon. Setting User Preferences The user can change preferences, such as search criteria or the I&O display. Changing Preferences is user specific and for all patient charts. 1. Click the Customize View icon. 2. Click the Preferences tab. 3. Make changes in the All My Views or the current view column. For example, to change the search criteria, click the drop-down arrow on Default Retrieval Type and select an option. 4. To change the defaults for just one band: a. Click the band on the Navigator. b. Click the Customize View icon. c. Click Preferences tab. d. Make changes in the middle column with the band name. Page 11 of 17

12 Make changes in this column to affect all the bands. The current band column. Change options in this column if you want just the one band affected. This column is the system default. Changes cannot be made here. Click the Reset System Defaults to restore the original defaults. 5. Click OK. 6. It is not recommended to change: Encounter Filter -defaulted to current encounter Display Rule - defaulted to last charted value Time Sequence -This changes it to be listed by chronological order Order Statuses - defaulted to discontinued and ordered Page 12 of 17

13 Filter The Filter pane is used to search for a specific result or result status of critical, high, low and abnormal. To search for a specific result: 1. Enter the name in the Find field. 2. Select the correct item. 3. Click the result to move the result into view. The result cells will turn green. To search by result status: 1. Click the check box next to the status. 2. Click the result to move the flowsheet. The result cells will turn green. Search Criteria Bar The Search Criteria Bar determines time frame for the data. Change the bar to view different data by one of the following: 1. Click the arrows at either end of the bar. 2. Right click and select an option. Timescale The time columns can be set for actual or time increments from q30 sec to q120hrs. 1. Right click on the date or time cell. 2. Click one of the options. Changes can be made to the Search Criteria Bar and the Time intervals that are specific to the user and affect all patient charts. Go to Setting User Preferences on page 7. Page 13 of 17

14 I&O Band The band s Navigator and View Pane function the same as the other IView bands: Click on a section in the Navigator to open or move it to the top of the flowsheet. Double-click the section header or time cell to activate charting. Right click to Modify, Add a Result, Unchart, Change Date/Time, Add a Comment and View Result Details. Add items to the I&O band by clicking the Customize button. For example, to enter blood product volumes go to Transfusions section on the Customize window. Additional functions and fields: Summary of today s and yesterday s I&O are at the top of the flowsheet. Fluid Balances are listed at the bottom of the flowsheet. Shift and 24 hour total columns display corresponding totals Intake-No Longer used and Output-No Longer used sections: Do not use these sections for charting. The sections are present for historical data from the old I&O. The Continuous Infusions rows are created by IV orders entered into PowerChart. Drip and Continuous IV volumes will automatically populate when the cell is activated. Rightclick and select Modify to change the volume. The Medications section is created when an IVPB is charted. The band allows textural documentation such as urine color. Page 14 of 17

15 NA I&O Nursing Assistants document I&O on the Nursing Assistant Monitoring band. The I&O sections work the same as the other sections. Charting IV Volumes Once a continuous IV or a medication drip has been scanned, the volume will default to I&O when the time column is activated. The volume is based on the charted rate. If the Begin Bag is not done, the volumes will not default to I&O (inpatient units chart in CareMobile, ED chart on the MAR). 50 and 26 auto- populated the cells when the column was activated. Page 15 of 17

16 Charting Medication Drip Rates Charting medication drip dose/rate and changes on IV Drips section will auto-calculate the volume on I&O when the column is activated. IV drip rates are to be charted hourly. Rate changed on IV Drips section of the Monitoring band. The charting must be signed before it will populate I&O. After refreshing the I&O band, the new volume auto-populated the I&O when the time column is activated. Page 16 of 17

17 Charting Frequent IV Medication Drip Changes Multiple rate changes within one hour will auto-calculate the volume correctly when entered on the IV Drips section. 1. If your flowsheet is set to 1 hour increments, click the Insert Date/Time Icon to add a current time column. You will not need to change the time. 2. Enter the changed rate/dose and sign. Actual time. Dose changed from 4 to 6 mcg/kg/min. Rate was auto-calculated with rate change. The next hour, the volume defaulted from the last rate entered. 6mcg/kg/min = ml/hr Discontinued IVs. Discontinued IVs, including medication drips will not auto-populate I&O. A volume may be entered manually. Manually enter a volume when charting has not been completed prior to the IV being discontinued. Page 17 of 17