Transcript System Sign-on - Scott & White Memorial Hospital

PCD TRAINING MANUAL
Licensed Staff
What is PCD??
“Patient Care Documentation”
Computerized nursing documentation
developed by Siemens’ company
On all hospital units except for ICU, ED,
Labor & Delivery, Post partum, NICU.
Adult ICU & PICU use the admission
history section only.
System Sign-on
The User ID & password are
your legal signature.
Always log off when the
transaction is complete.
Never allow anyone else to
use your password.
Contact the Help Desk (42501) or log into Passport
to change your password*.
A record is kept of all
transactions.
Your Sign-on is last three
characters of your
mainframe sign-on;
example: 123ABC
Your Password is your
mainframe password:
random letters & numbers
assigned by IS.*
Nurse Station Census
Net Access navigator bar.
Can be used to locate patients
by name or MRN inquiry.
The unit census defaults to
where the user signs on.
Nurse Station Census
View census of another unit by
selecting Unit Census
from the Navigator Bar and choosing
the unit
Patients are listed in Room/Bed order,
Name highlighted in blue and underlined
Click once on the patient name to select patient.
More Navigator Facts
Once a patient is selected, different
functions are available.
The patient’s name and the user ID display at the top of the screen
Items preceded by a sphere display multiple options when item is selected
Vital Signs
Charting Vital Signs
Defaults to current time,
may change date and time.
May chart past 48 hours.
Can NOT chart in the future
Use spin buttons
or free text the values
These are
now
mandatory
Move from field to field using mouse or tab key
Charting Vital Signs
Three places available
for orthostatic B/P’s
Now mandatory
To add more vital signs, Click here.
Click update complete to chart
This is your “save” button
Click on cancel to
exit pathway without
entering data.
Revise Vital Signs
Indicates the person
Entering the data
*****Only Licensed Staff can revise vital signs:
RN anyone
LVN only their own
CNA cannot at all
Revise Vital Signs
From the vital display, select data to be revised
Then click on revise.
Only licensed staff can revise:
RN revises anyone
LVN revises only their own
CNA cannot revise at all
Revise/Delete Vital Signs
Choose a radio button:
1. Revise result to change incorrect data on correct patient.
2. Mark as error to delete data entered on wrong patient.
Once chosen, fields are enabled to allow revision.
Make changes and Click OK.
When using Mark as Error,
A reason must be entered.
Using skip button allows
user to leave screen
without making changes.
Display Vital Signs
This displays the last 5 sets of VS.
To see all since admission, click all.
Revised VS will display this way showing
Incorrect data as well as corrected data.
Vital Signs mark as an error display this way
Intake and Output
I&O
Entering I&O
Select box in front of source to
delete a source that is no longer
needed. The box will be grayed out
if data has been entered in the last
24 hours (it cannot be deleted).
Approximations will not
be added to totals.
They will appear as “+”.
Enter
amount of
intake or
output in
mls
Excluded
sources are
not included in
the I/O totals.
An “X” will
display in the
excluded
column. IE
Stool Count
Enter the date/ time
I & O collected
Click OK to store data
Select Add Comments to
Enter additional data about I&0
Comments
A comment field is provided
For each I&O source
Click OK when completed
Intake & Output Sources
Select intake or output to
add sources
Click Add when
desired sources
have been
selected
Revise I&O
Only licensed staff can revise:
RN revises anyones
LVN only their own
CNA cannot revise at all
Shows the date/time interval
for the displayed data.
Select the item(s) to be revised
Click revise
T indicates comment
Revise I&O
Choose radio button:
1.
Revise result to change incorrect data on correct patient.
2.
Mark as error to delete data entered on wrong patient.
Once chosen, fields are enabled to allow revision.
Make changes and click OK
When using Mark as Error,
A reason must be entered.
Using skip button allows user
To leave screen without making
changes.
Display I & O
Shift times in columns link to
additional information
“T” indicates a comment was
added.
Sources marked excluded will not
show in the total
Chart Assessments
Admission/Shift/Focus/Discharge
Assessments
Create New Assessment
Date and time should
reflect actual date and
time assessment
was performed.
Select assessment type and
click begin
******Documentation choices depend on job title.
Admission Assessment
Selecting ‘Required Assessments’ automatically selects the Admission History, Body
Systems, Fall Risk, Pneumonia/Flu, Sepsis Screening and Education. Others may be
selected as needed. Each system displays in the order they appear on this screen.
*****Assessments can only have one time
assigned to that assessment. If the LVN does the
adm hx, RN who completes the admission must
time her assessment at least 1 minute later.
From this screen document Admission History,
Admission assessment, ad other needed
assessments, ie, pain/ comfort or restraints.
Select chart detail to continue
Admission History
Ask the patient each question in the admission history. Only
applicable data is actually entered into the system.
Adult ICU, PICU and CCH only
do Admission History,
Arrival Date/Time must be entered
Opt Out is a mandatory field.
Answering “yes” only indicates that
you have offered the patient the option
not whether they want to opt out or not.
‘…’ indicates additional screens
will appear if the item is selected
Admission History
Personal Belongings
You must describe clothing, cash,
jewelry, other
Use these buttons to move
between screens
Location is mandatory
if the field is selected
Admission History
Nutritional Screening
Not required but useful information
Selecting any
of these
will send a
consult to
Nutrition
Services
Admission History
Chaplain Referral
Selecting “chaplain referral” will generate automatic consult
These fields are
mandatory.
Cannot move forward
until completed
Admission History
Continuum of Care
Anticipated discharge placement
Selecting any of these will
generate a referral
Admission History
Advance Directives
Executed Advanced Directives is a required field
Admission History
Past Medical/Surgical History
This screen allows you to collect data
regarding existing conditions that may
affect the care during this admission.
Enter date of vaccination if known,
You can check ‘Immunization History” in
Navigator bar for immunization date
status if unknown. This is S&W info only.
RN’s – select
continue to move
on to physical
assessment.
LVNs may only select “Update Pending”
Update Complete will be grayed out
Pneumococcal Screen
18-64 yr old must have a
chronic illness to qualify.
Chronic illness box lists
example diagnosis
Screens are age based:
Either > 65 yrs of age or
18 – 64 yrs of age
Patients in
SWMH ICU
are not
screened for
vaccinations
This
question
refers to
this group
or
questions
only
Flu Screen
Verify that months are within flu season
Verify if flu vaccine already given this flu season.
Refer to immunization history in navigator bar.
Make sure you update/ pend before opening
immunization history as it will kick you out
and will lose everything you just entered.
H1N1 Screen
H1N1 to be given until further notice from Administration
Patient must:
1. Review H1N1 protocol
2. Meet protocol
3. Consent to vaccine
If any of these do not
occur, patient does not
receive vaccine
Assessment
Within Defined Limits (WDL)
“WDL All” indicates your assessment meets the defined limits
Select “except for” to document exceptions to WDL.
Assessment
Cardiovascular
Most selections can be entered via the point and
click method using the radio buttons,
Checkboxes and free-text data entry fields
Remember any choice with
“…”, additional screens will
need to be completed
Assessment
Edema
Click the
“Grade” button
for definitions
Assessment
Braden Scale
Braden scale must be assessed every shift
Document any skin
abnormality on this
screen
Braden Scale
Select either tab or button
Select appropriate
descriptor or free text
number in box
Click “Close” or “Continue”
to see Braden total score
Click here to
access skin
care policy
Assessment
Fall Risk
You must select either
“no fall risk”
or one or more of the
risk factors listed to
proceed.
Fall Risk Interventions Screen
Standard precautions always
necessary for a fall risk patient.
Then, choose any
other precautions
done to protect
patient
Initial Restraint Documentation &
Every 2 hour CMST Checks
Initial Restraint Assessment
Restraint assessment must be made prior to applying
restraints. Document all actions taken prior to application
of restraints.
This is usually a “focus “note
Family and patient must be
informed of reason for restraint
usage
Restraint Assessment
Document all
alternatives tried and
responses to those
Restraint Assessment
Initial CMST (Circulation, Motion,
Sensation, Temp) check
RN must assess for continuation of
restraints or not
Every 2 hour CMST Checks
Change date/ time as needed to
reflect required q 2 hour
restraint documentation.
Document Restraint data here
Items clicked yes
require description
Document
interventions every
2 hours and add
comments as
needed
Click update complete to
store data
Sepsis Screening
Shift and Focus
This is an example of a patient who is septic but not in severe sepsis or in shock.
This screen walks you through the process of identifying a patient who is either:
1. septic (has an infection UTI, Pneumonia, wound infection)
2. In severe sepsis
3. In septic shock
This is done q shift on all units. If a patient’s status changes, can be a focus note.
This identifies that the patient has more than 2 SIRS and a known or suspected
infection. The patient has not had a serum lactate greater than 4 or organ failure
Positive Sepsis Screen
This screen has identified a patient who has gone from severe sepsis to shock.
1. The patient had 2 or more SIRS with a suspected or known infection
2. A lactate acid or 4 or greater within the last 24 hours
3. Patient has not had response to fluid challenge to increase B/P
4. Patient has one or more organ failures.
Identification of Severe Sepsis or Septic Shock will trigger the pop up box to notify PCP and call a
Dr. Rapid.
Make comments in the comment box as to what was done in regards to this patients positive
screen.
Assessment
Storing Data
Assessments that were visited are underlined.
Last chance to go back and address any initial assessment
you may have missed.
Select update/complete or update/pending
to save entered data
Shift/Focus Assessments
Admission History not an option on this screen
Required assessments include body systems, fall
risk and education
Other options, ie, Peripheral IV, Pain/Comfort, etc.
may be added as appropriate
All other steps are the same as the admission
assessment
See next slide
Shift/Focus Assessments
If Shift or Focus Assessment is selected this screen will appear.
Admission History is not an option.
‘Required Assessments’ automatically selects all the Body
Systems, Fall Risk, and Education.
Others may be selected as needed.
Each system displays in the order they appear on this screen.
Select chart detail to continue
View Assessments
Click to view assessment,
select assessment,
and click view.
View Assessment
This is how data displays when
“View Assessments” is selected
Change/Delete Assessment
Select Change/Delete Assessment,
the assessment to be changed or deleted,
then click the appropriate button for that function.
Change Assessment
Only change your own assessments
Guidelines for Change Assessment
Use Change when you need to modify
an existing assessment that you have
created. This will not create a new
assessment or change the date and
time of the original assessment.
Delete Assessment
This is the final screen before you delete an assessment
Only delete your own assessments.
Guidelines for Delete Assessment
Use Delete when you have charted on
the wrong patient.
Delete only your own assessments
Complete Pending Assessment
Select “Complete Assessment”,
choose assessment in pending
status (P),
then click complete.
Discharge Assessment
Enter date/time the patient left the unit.
Not the time of the discharge order
Click continue to move to next screen
Discharge Assessment
Document discharge education,
patient response,
and pain status at time of discharge
This question
asks if
immunization
status was
assessed.
Indicates if administration
of vaccine occurred.
Patient Notes
Patient Notes is the opportunity to include a narrative note referring to patient care issues not
addressed by any assessment pathway.
Ex. Response to treatment, untoward events—falls, codes, etc.-- or Nursing Diagnoses not
addressed in assessment pathways