New Employee Orientation. Nursing Documentation For PCT/SPCT

Transcription

1 New Employee Orientation Nursing Documentation For PCT/SPCT

2 Obtaining a Form to Chart Scheduled tasks from physician orders and scheduled routine nursing documentation forms will display on the task list. Always look on the task list to find a form for ordered or routine tasks before looking elsewhere to open a form to chart on. If you need to document a particular patient care activity or patient assessment for which no task exists on scheduled patient care, all prn tasks, all continuous tasks or nurse collect task tabs, you may choose the necessary form from the folders found in the AdHoc Charting icon.

3 AdHoc Folder All PowerForms used in the Medical Center and Children s Medical Center can be obtained from the AdHoc folder. (If an appropriately timed task is associated with a form, the form should be documented from the task list.) To find a form, click the AdHoc icon. A list of folders available for your position will open. AdHoc icon To select a form to chart, click in the box to the left of the form name. After selecting as many forms as appropriate, click on chart. If more than one form was selected, the next form will open automatically after signing each form. To follow along with the training, you may choose any form from either the task list or AdHoc folder. Not all the types of documentation fields are found on forms for the non-licensed staff. Most of the information can be seen in the Adult or Pediatric Basic Care, Nursery Basic Care, Glucose Monitoring Record, and Vital Signs forms. The exact form you choose does not matter. The information in the training covers general charting guidelines.

4 Guidelines for Completing Forms Tabbing is the most effective way to navigate through the fields on a PowerForm. Tabbing automatically guides the user through all available questions. Forms are designed with a Question followed by an answer box. Examples of the various types of answer boxes are demonstrated below. For multiple choice answer boxes, an answer is selected by left clicking in the box and unselected by left clicking again. Displays the form name and patient name Section name Icons Sign Form Navigation Pane Use the Navigation Arrows or click to move through the sections on the section Cancel Charting Clear Form Result Info Navigation Arrows Clinical Calculator

5 Single Select Answer Box (circles) Only one selection is allowed by left clicking on the options circle near the response. To Unselect a previously chosen answer, click the response again. Multi Select Answer Box (squares) More than one selection is allowed all that apply may be chosen by clicking the options square near the response. To Unselect a previously chosen answer, click the response again. Patient can only be admitted from one location. Patient could have more than one type of equipment. If none of the choices offered are appropriate, the Other option opens a free text box which allows the clinician to enter data.

6 Multi Select First Single Select Answer Boxes (squares) With this type of answer box, the system knows that if one circumstance exists another cannot. For example, if No one accompanied pt is chosen, it rules out that a Spouse can also be chosen in the same answer box. Patient Specific Responses Some responses vary according to the patient s age and sex. For example, if a patient is Male, pregnancy status would be N/A. If the response is the only logical response to the question, the field pre-fills. An Icon denotes a pre-filled filled field. If No one accompanied pt is selected and then another option is selected (ie Spouse ), No one accompanied pt will uncheck itself because those two conditions cannot exist at the same time. Only logical choice for a male patient Choices for a female patient Other examples where the default icon appears are answers to questions that are the same for most patients. All patients are on standard isolation precautions at a minimum. The nurse can change the option as appropriate. Once an option in a pre-filled answer box is changed, it holds the last charted value until changed again.

7 Free Text/Rich Text Free text boxes allow the user to type up to 255 alpha or numeric characters. Rich text boxes allow the user to type unlimited characters. Numeric Responses Numeric response boxes only allow numeric entry. There may be feasible parameters for these entries. A warning will display when signing the form if the value is outside the feasible range. Most numeric boxes will show the unit of measure that should be entered and an automatic conversion displays to the right of the numeric box. Automatic conversion from kg to lbs and cm to inches A pain score of 60 is not feasible. An error message displays

8 Conditional Questions/Triggered Sections Conditional questions and triggered sections are dithered (grayed out) and will only open when a related question triggers the response box to allow data input. Answering Yes to Do You Have Pain Triggers the Pain Assessment Section to open. When a No response to Do You Drink Alcohol is chosen the alcohol frequency questions remain dithered. When a Yes response to Do You Drink Alcohol is chosen the alcohol frequency questions are available for charting.

9 Required Questions Required questions are indicated by a yellow background. Once the question is answered, the background turns white. If a section on a form has a question with a required field, a blue X displays before the section name on the navigation bar. Once the required field is completed, the X becomes a check. Indicates a section has an incomplete required field Yellow indicates a required field Indicates a section had required fields and that they have been completed.

10 Adding Comments-Comments can be added to any answer box after charting in the box. To add a comment: 1. After selecting an answer or charting in the answer box, right click in the box. 2. Select Comment. 3. Type your comments in the popup box and select OK. You will not be able to see the comments until you sign the form. 4. Open the form from the form browser, go to the question in which you entered a comment and you will see a green push pin next to the answer box. 5. Right click on the pushpin, select comment, and you will be able to view the comment entered.

11 Documentation Grids There are three types of grids used to document. Discrete Grid-Data is entered into a discrete grid by clicking in a cell. Clicking puts a X in the cell. To clear the cell, click again. A comment can only be added if there has been a selection made in a row. In this example a comment can be added to the LUQ and RUQ rows but not the LLQ and RLQ rows. To add a comment click in the comment box on the appropriate row and begin typing. Ultra Grid-Clicking in a cell on an ultra grid opens a response box from which choices are selected. If <Alpha> displays in the cell, one choice may be selected. If <MultiAlpha> displays in the cell, more than one response may be selected. Click the cell to open the response options Power Grid-Data is entered into a Power Grid just as it is into an ultra grid. However, by right clicking in the grid cell, an additional row may be added.

12 Automatic Calculations Several forms use numeric scores to determine risk. When all questions used to determine the score are answered, the score will automatically calculate and be viewable in the score box. Calculated scores cannot be manually altered.

13 Reference Text Reference texts are embedded within PowerForms and allow the user to access policy, procedures, guidelines, and patient education. The blue text will give instructions for accessing the reference material. Right click in the answer box to open the Reference Text option. Open the policy link. The link opens the appropriate policy, procedure, guideline, or patient education.

14 Signing Documentation When you are finished with the completion of all appropriate questions on your form, you must sign the form to place the information in the patient medical record. You do not sign the form after each section of the form. Sign the form when you have completed all the sections of a form or if you need to leave the computer. Partially completed forms can be found in the Form Browser tab to open and complete at a later time. To sign the form, click the green check mark in the upper left corner of the form.

15 Form Browser Signed forms are viewable and can be modified from the Form Browser tab. Several sorting options are also available. The color of the icon located before the date is significant. Yellow icons indicate a form was charted in error and has been uncharted. A red line will display through the form name of forms which are errored out. Red icons indicate that there are required fields on the form which have not been completed. A blue icon indicates that all required fields have been completed. Per MCG policy, assessment forms may be completed by an LPN or a graduate nurse, but they must be co-signed by an RN. Forms requiring co-signature display (Unauth) after the form name. To open a signed form, right click on the form and choose view. If a form was charted in error, choose unchart. History opens a detail screen showing who charted/changed a form and when. Options available by right clicking on the form.

16 Modifying Forms Incomplete forms may be completed by choosing the modify option. This option opens the form so changes can be made and the form can be re-signed. The PCT cannot modify a form that has been signed by a licensed nurse. Modified-Multi Contributors will display after the form name when more than one person has charted on the same form. To view the contributors, right click and choose History.

17 Clinical Flowsheets The clinical flowsheets tab compiles information documented on other forms and tabs. Data is organized into a flowsheet that shows change over time.

18 Precautions Flowsheet Specific information entered into the medical record through nursing forms automatically flows to the Precautions tab. The precautions tab contains information related to basic patient safety information which may be needed by any staff coming in contact with the patient.

19 Respiratory and Vital Signs Flowsheet Information documented on forms flows to the Respiratory Flowsheet and the Vital Signs Flowsheet as appropriate. Information cannot be documented directly on the flowsheet tabs.