Intensive Care Unit and Paediatric Intensive Care Unit Essential Toolbar Buttons

Transcription

1 Intensive Care Unit and Paediatric Intensive Care Unit Essential Toolbar Buttons The following buttons are situated on the PowerChart Toolbar which are commonly used throughout the Digital Release. Care Compass The Care Compass button is the new landing page for Ward Nurses. When you first log into PowerChart the Care Compass screen will be blank until you create a Patient List. The Patient List button will create a list of all patients currently admitted to ICU and PICU on HBCIS. Note: if you double click on a Patient in the list it open the medical record. Change/Exit The Change button can be used on any screen and at any time to switch between users (ie switch from RN to DR and back to RN). Note: Only one patient can be open for this function to work. The Exit button is the correct way to log out of PowerChart, and will ensure data is saved.

2 Do NOT exit with the. This does not enable the iemr to close correctly and may not save favourites. Patient Search Button used to search for patients who are not in your patient list. The best search is via UR number and the first three letters of the surname. Specimen Collection The Specimen Collection button allows you to collect specimens. Refresh Button The Refresh button allows you to refresh the screen once you have added some vital information or made some changes to the patient s chart. It is important to remember to refresh the screen on a regular basis on every screen. The Refresh button also indicates how long it has been since the screen was last refreshed.

3 Home Button The Home button allows you to quickly navigate back to the SBAR Patient Summary screen that you were last on. Customising the iview profile page To customise the iview profile page: 1. Click on the Customise view icon A new window will open where individual user preferences can be selected. This window contains three tabs: 1. Customise tab: applies changes to the individual patient record 2. Preferences tab: applies changes across all patient records 3. Dynamic Groups tab: activates/inactivates dynamic groups Customise tab The Customise tab will display fields specific to the Band currently displayed on the iview flowsheet, and is used to: 4. show /hide Sections within the Navigator 5. show/hide fields within the iview flowsheet 6. shows Sections within the iview flowsheet by default on selecting the Band The Customise tab is used to apply individual user preferences for the current patient medical record only. To view the Sections within a Band: 1. Select Collapse All The view will change to display only the Sections within a Band. To view all fields contained within the Sections: 1. Select Expand All Sections Fields

4 Showing/hiding Sections and fields To show/hide specific Sections within the Navigator: 1. Click on the check box under the On View column relevant to the Section you want to show/hide 2. Click OK The window will close and the iview profile page will be displayed. Any Sections that have been selected will now show in the Navigator. Any Sections that were deselected will now be removed from the Navigator. To hide/show specific fields within sections: 1. Click on the check box under the On View column relevant to the field you want to show/hide 2. Click OK Any fields that have been selected will now show in the iview flowsheet. Any fields that were deselected will now be removed from the iview flowsheet. To show specific Sections within the Navigator by default: 1. Click on the Default Open checkbox for the Section level heading required 2. Click OK The new display will now be customised to an individual s login. Finding a specific field There are many fields to select or deselect on the Customise tab. The search function is available to aid in finding a field. To find a specific field in the Customise tab: 1. Click on the Search for Item drop down arrow 2. A menu will display containing all fields for the selected Band, select the relevant field. The window will update to display and highlight the selected field. 3. Continue to select or deselect as required. Highlighted field Search box Frequent Actions The following are frequent scenario s that may be utilised within Intensive Care Unit. Inserting a Central Line Navigate to Interactive View, select Adult Lines-Devices, Central Line, click on the cubed box (dynamic group), then enter details for the central line. Click OK.

5 Double Click on header box for the central Line, this will enable documenting in the column for the central line. Either tab to drop down a row or click in the cell to enter the relevant details regarding the line. Inserting a Peripheral IV Line Navigate to Interactive View, select Adult Lines-Devices, Peripheral IV Line, click on the cubed box (dynamic group), then enter details for the peripheral IV line. Click OK. Ensure for activity you choose present on admission, so that you can document an insertion date and time.

6 Double Click on header box for the peripheral IV Line, this will enable documenting in the column for the central line. Either tab to drop down a row or click in the cell to enter the relevant details regarding the line. Double clicking in one cell will open that cell for documentation only. Ensure for activity you choose present on admission, so that you can document an insertion date and time.

7 Inserting a Urinary Catheter Navigate to Interactive View, select Adult Systems Assessment, Urinary Catheter, on the cubed box (dynamic group), then enter details for the catheter. Click OK. Double Click on header box for the Urinary Catheter, this will enable documenting in the column for the central line. Either tab to drop down a row or click in the cell to enter the relevant details regarding the line. Inserting a Surgical Drain Navigate to Interactive View, select Adult Systems Assessment, Surgical Drains / Tubes, click on the cubed box (dynamic group), then enter details. Eg, Nasogastric Tube or Suction Bellows / Bulb. Click OK. Double Click on the box adjacent to the Tube / Drain and enter the relevant details.

8 Documenting a Wound in Interactive View To document details of a wound the user needs to firstly enter the wound details by adding a Dynamic Group or Label. To add a Dynamic Group 1. Click on the Interactive view patient menu page 2. Click on the relevant Systems Assessment band, either Paediatric Systems Assessment or Adult Systems Assessment 3. Click Incision/Wound Section 4. Click on the Dynamic Group icon, the Dynamic Group label window will open iview section Dynamic Group icon within a section 5. Complete the Dynamic Group Label window details. Click the relevant wound Location, Laterality and Location Description details. Use the scroll bar to see all available descriptors.

9 6. Click button The Dynamic Group label information will now display as a sub heading under the Incision/Wound Field see example below. Check the correct wound description is displayed, e.g. <Calf Left Deep> To edit the Dynamic Group label, double click on the wound label/heading to open the window, amend as required. Documenting in the Incision/Wound Cells 1. Double click the grey cell next to the wound Label. This will allow you to sequentially click and tab through each cell. Double click empty cell next to Wound Label 2. Click the relevant empty boxes within the Wound Pattern window, eg Raised, press Tab. Sections that have square check boxes can have multiple options checked. 3. Continue through, appropriately documenting against all relevant areas. Note: Conditional Field symbol. Some wound types will trigger further fields and cells to display eg. Burn, Pressure Injury and Rash see example below. Document in each additional cell as required 4. Click Sign

10 You can also perform several functions from a populated cell. To add a free text comment, right click, and click Add comment. To clear cells, right click, click Clear To add a flag, right click, and click Add Flag. To add a flag with a comment, right click, and click Flag with Comment. Flagged Comments can be viewed in the Patient Summary menu page, in the Flagged Events widget. Pain Documentation If wound pain is present or experienced during dressing change, this will need to be documented under the Pain Assessment section in Adult or Paediatric Quick View section. Document only what is applicable to your patient s pain experience. 1. Access the Interactive View patient menu page 2. Select Adult/Paediatric Quick View band 3. Select Pain Assessment section 4. The Pain Assessment fields and cells will now be on view. 5. Double-click in the dark blue cell next to Pain Assessment to start documentation. 6. Document Pain Present Double click this cell to activate the section for documentation

11 iview Fluid Balance Charting 1. Log into iemr and create a relationship with the patient 2. Open the patient s chart 3. Click on Interactive View tab in the main menu down the left side of the page 4. In interactive view click on the Fluid Balance navigator banner as shown below 5. To input information, double-click on the grey banner required as shown below. This will highlight the column and allow you to input information required 6. When finished charting, click on the green tick to Sign the documentation. Navigate to Patient Summary, the fluid balance calculation is available for viewing at a glance

12 Inserting Vital Signs Navigate to Interactive View, select Adult Quick View, then Vital Signs. Double click on the dark blue header for vital signs. Document and then remember to tick to sign the results. Placing Orders The Orders section of the Patient Medical Record allows electronic requests to be made for radiology, pathology, patient care tasks and inpatient consults How to place an order 1. Open the patient s medical record and select the appropriate encounter 2. Select Orders from the Patient Menu 3. The Orders profile page will display 4. Click the Add icon in the top left of the Orders profile page OR Always check the Orders section of the patient s chart before placing orders to avoid duplicates. 5. Click Add in the patient Menu next to Orders 6. Enter the name of the required order

13 Type the order you require in the search field 7. Select the correct order by single clicking on the title from the list that populates in the window below. The order will highlight in blue when it has been selected You may have to change the search criteria between Starts with and Contains to assist you in locating the correct order Click the drop down box to change search criteria between Starts with and Contains The Contains search requires at least 3 characters to search, the Starts with search only requires 2. Inpatient pathology orders placed on iemr will not require a paper requisition form to accompany the specimen/s. For patient s requiring internal or external outpatient collection, a requisition form must be printed from the system to give to the patient. Transfusions and Cross-match requests will remain on paper. 8. The Ordering Physician may appear for orders placed by Nurses or Allied Health staff as they may require co-sign. The Ordering Physician window will appear with a mandatory yellow field to enter the Physician Name, click OK once you have searched for the correct clinician and selected the appropriate Communication Type.

14 The Communication Type refers to the method of communication for the order. If results are applicable to the order, they will return to the ordering clinician and nominated physician. You should only place orders that are within your scope of practice Selecting Phone or Verbal (co-sign) will send a message to the selected ordering physician to notify them of the order(s). Selecting Written (no co-sign) will not send a notification to the ordering physician. A selection of Protocol means that ordering these tests is within your approved scope of practice and a Unit Based Protocol supports this order. Once the ordering physician s name has been entered, the system will automatically populate the Ordering Physician window again. It assumes the same physician, previously entered, has requested the next order requiring co-sign. Once you have closed down the patient s chart, this will reset. To select a different ordering physician, click Done, right click on the order and select Ordering Physician. 9. Follow the previous steps to search for more orders 10. Click Done to return to the Orders for Signature window when you have selected all relevant orders 11. Complete the order details: Enter order information in Reason for order/details. This will be printed on the requisition form. Use this field to convey any order or clinical details. Check the Requested collection time. Specimen collection orders are valid for 366 days. Generally, specimen collection orders are collected in the Collection Details screen. However, 15 days after the order date the specimen collection details are no longer viewable in the Collection Details screen.

15 If the specimen will be collected as an outpatient, forward date the Requested collection time to past the anticipated date of collection. Ensure correct Specimen type and Body site if appropriate If the specimen is to be collected by a nurse or Doctor, click Yes for Clinician collect. If the specimen is to be collected by a phlebotomist, click No. Select Routine or Urgent in the Collection Priority field if the sample is for Clinician collect. The order will be ready to collect once the order is signed. If the sample is for inpatient Phlebotomy collection, selecting Routine in the Collection Priority field will schedule the specimen to be collected on the next Phlebotomist round. Selecting Priority AM/PM or Routine AM/PM will schedule collection at the set AM/PM Phlebotomist rounds. There are a number of inpatient AM collections runs with Individual wards have different collection run times (please check with ward for allocated times). The PM collections runs are 12.00pm. Ensure the order is placed at least 15 minutes before the designated run. Doctor/Nurse to collect Phlebotomist to collect The order will be available for collection immediately in the Collection Details window when selecting Urgent in Collection priority even if it is designated for phlebotomy collect. Generates Add On order Urgent orders will be available for collection immediately regardless of the clinician collect status Clinician Collect: No - will place the order on the selected scheduled run. Clinician Collect: Yes - the order will be available for collection in the Specimen Collection window after signing. Ensure the Collected field is always set to No, unless you are placing an Add On order. This ensures that you are able to print off specimen labels.

16 If you have selected Collected: Yes and have not printed off labels after signing the order, refer to the QRG on reprinting labels 12. Continue to fill out any other relevant information including Requestor contact/phone pager, Fasting Status, Patient Status. 13. To communicate additional information to the lab, use the Order Comments tab. Any details entered in the Order Comments tab will not be printed on the paper requisition form. 14. Click Sign, enter your password and then click OK to finalise the order/s. 15. To remove an order from the Orders for Signature window, right click on the order and select Remove Click Sign when finished, enter your password and click OK 16. You will have to refresh the screen for the order to update from Processing to Ordered. If you have multiple orders in the same category (eg Patient Care), to modify multiple Details about these orders, hold down Ctrl on your keyboard and use the left mouse click to highlight multiple items. When you enter the information in the Details window, this information will update all the orders selected A white cross in a blue circle icon indicates that mandatory order details are not complete for that order. Specimen Collection Specimen Collection uses positive patient identification checks and scanning to record collection and print labels in PowerChart. The Specimen Collection window can be launched within a patient s chart. The Specimen Collection button appears in the iemr toolbar. Collecting a specimen To collect a specimen for a patient: 1. Open the patient chart in the appropriate encounter the specimens were ordered. 2. Click Specimen Collection from the iemr toolbar 3. The Collection Details window will open. Confirm the patient s identity. 4. Scan the patient s wristband using the barcode scanner OR 5. Click on if a wristband is not available 6. The Collection Details window will open and display a list of orders available for collection in the selected encounter

17 Filter Refresh Indicates priority or urgent collection Print icon Suggested pathology specimen containers will be displayed under the test/s name. These may need to be cross referenced with your hospital policy. Do not select Not Collected, as this will cancel the order, or Reschedule. 7. Hover the mouse over the name of the specimen to view a text box with details of the collection To print out specimen labels, click on the Print drop down arrow 8. Select Print All Labels. The Print Labels window will open. The Select All check box will be selected as a default. All specimens will have the corresponding checkbox ticked. 9. Select required specimen labels for printing 10. Select the printer. 11. Click the Print button 12. The label/s will print to the selected printer. 13. Once the specimens are in their containers, initial and time and date the label/s. Affix the appropriate label to the correct collection container. The barcode must be horizontal and straight, and over the existing tube label. 14. To communicate if the patient is fasting or if the specimen is urgent/critical, use the appropriate stickers and attach to the lid of the specimen. Write any additional comments relating to the collection on the specimen label or on a note placed in the specimen bag with the container. 15. Use the barcode scanner to scan the labels attached to the specimen containers. The system will confirm that the patient chart and the specimen container label are matched to the correct patient. The specimen order will be displayed with a tick to indicate it has been collected. 16. If a barcode scanner is not available it will be necessary to manually change the collected status from the Specimen Collection window. Hover the mouse over the specimen collected, the line will highlight and the Status menu will be available. 17. Click on to the right of the specimen order

18 18. A menu will be displayed. Select Collected. 19. A warning message will display as the label was not scanned. Click Yes if you have verified the container and label. 20. Click to certify you have collected the correct samples from the correct patient and labelled each container appropriately. The status of the specimen will automatically change to Ordered (Collected) in PowerChart and will drop off the Specimen Collection window. Marking the samples as Collected will create an entry in AUSLAB for the tests indicated on the label. 21. Click Close to close the Specimen Collection window.