clinical documentation introduction to:...

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Clinical DocumentationIntroduction to:

Flowsheets

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Introduction

This slide show is designed to give you a basic overview of Flowsheets in SAC (Sunrise Acute Care) system, before attending class.

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Background

Eclipsys electronic clinical documentation is generally a “point and click” system that allows you the user to chart simple to complex notes with just a few clicks of the mouse

This slide show will provide an overview the terminology and mechanics of entering data into flow sheets.

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Overview

All of our documentation should work together to form a picture of our patient’s condition, treatment, and outcomes.

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Patient

Education

Discharge

Planning

Daily Nurses

NotesOrders &

Results

Ancillary

Depts

Care Plan

Med AdminAdmission

Assessment

Procedures

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A flowsheet is a document that contains information that is entered repeatedly across time, such as Vital Signs and I&O.

It is usually set up in a grid format with time columns.

Flowsheets

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Vital Sign Flowsheet

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What do they all MEAN??

There are lots of new terms you will hear when learning about flowsheets

Time Columns

Observations

Parameters

Lists

Cell

Value/Data

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Flowsheet Terms

Time Column

Observation

Parameter

Value/Data

Cell

Flowsheet TAB

To get to the flowsheet, first select your patient from the patient list then select Flowsheet from the tabs

or the icon

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Documenting on a Flow Sheet

To chart on a flowsheet you must choose the correct flowsheet from a list in the lower left corner

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Adding a Time ColumnTime Columns may already be created on the flowsheet

when you open it. However there may be situations,

where you may have to add a time column. Examples

would be charting a follow up pain assessment or your

patient becomes feverish.

To add a time column:

1. Right-click on the top of any time column.

2. Select Add New Time Column

3. In the “Set Date Time” dialog box, choose the appropriate

date and enter the time.

4. Click OK.

5. Your new column should now appear on your flow sheet.

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Right ClickHere

Type in thetime here

and click OK

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New TimeColumn

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Observations

What are Observations?

Observations are the data elements clinicians collect about patients

Temperature

Blood Pressure

Pain

All are examples of Observations.

Sometimes they are also called parameters

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More about Observations (they must be important)

Some observations are on the flowsheet as soon as you open the flowsheet These are observations that all patients need to have

documented. Temperature, heart rate, blood pressure, are examples of

these types of observations.

Some observations have to be added These are observations that not every patient would

need charted Capillary glucose would be an example

If the observation you need isn’t on the flowsheet it must be added.

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Adding an Observation Parameter

1. Right-click on an observation parameter or in the

gray area at the top of the flowsheet

2. Choose “Add Parameter” from the drop-down list

3. A box opens with the parameters available to be

added to the flow sheet

4. Click on the parameter(s) in the left box and click

the Add button.

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Right Click inThis Area

Select addParameter

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Add the observation you want from this side, then click add,

then click OK

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The newObservationis added to

the flowsheet

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Documenting an Observation

1. Some observations are numbers

• Temperature, Heart rate

2. Some are values picked out of a list of choices

• Pain location, Blood pressure reading location

3. Sometimes, the value you want won’t be on the

list and you must type it in.

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Different ways of charting an Observation

The (degrees F) observation is a numeric value noted by the ### in the cell

You can only type numbers when you see this type of observation

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The site however, is a list value.

Click in the circle (also called a radio button) and select where you took the patient’s temperature.

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List Choices SAC uses 2 types of lists: suggested and

restricted. Note the Restricted list does not have an empty box at the end of the list

Restricted, you must select a choice provided

Suggested, you mayselect a choice or type one

of your own in the box

In the previous slide I typed “PVC” in the box, here is how my choice is displayed:

When the cell is too small to display the value a blue arrow is displayed, hover with the mouse to see the value

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More about ListsThis box filters the list choices to findthe one you need

quickly

Again if your choiceisn’t in the list

you can type your own

By typing“L” in the boxnow you canonly see thechoices that

start with “L”from the list

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One more thing about Lists

Sometimes you can choose more than one choice from a list.

A list with radio buttons (circles)means you can only

choose one choice in this list

A list with check boxes (squares)means you can choose one or more

choices from the list

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Ok, I’ve entered my informationnow what?

After you select save, enter your password, and you are done.

Once you’ve enteredyour observations, click the

Save button

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What do the arrows mean?

A single or set of two red arrows display

above your observation, this means that the

observation is out of range—high or low—to

alert you of the fact. A double red arrow

means a critical value.

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What if I make a mistake?

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Nobody is perfect, so there will be times when you will

need to correct your work. If you make a mistake,

simply click on the cell where you need to make the

change and enter the correct information.

Remember, you must save your work before leaving

the flowsheet.

A red C will display above any corrected data.

Oops!

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Conclusion

This ends the intro to Clinical Documentation Flowsheet slide show

This slide show is not intended to replace classroom training or practice, it is only to serve as preview of the system prior to attending class.