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Clinical Documentation and Order

Entry:

Nursing Activity Guide

(Meditech via Zoom)

Page numbers herein refer to relevant pages in the Clinical

Documentation and Order Entry workbook available online

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Review the case below and complete the activities, using the information provided. Know

that goal of this Meditech training is to become familiar with Meditech, not create a perfect

case study so don’t get caught up looking for details here to enter into Meditech – if

necessary make it up!

Admission: Mrs. Jones has been admitted to your unit via ED with failure to cope after a

fall. You have completed your assessments and she is now settled. You are ready to document.

CARE PLANNING - SELECTING AN INTERVENTION SET (PAGES 4-7)

1. Add the MED Inpatient intervention set

DOCUMENTING AN INTERVENTION (PAGES 8-18)

2. Document the GEN Med/Surg Admission assessment, which was performed at 7:30 in

the morning, be sure to include:

Past Medical and Surgical History

i. Type 2 diabetes, COPD, Hypertension, previous surgery for breast cancer

Admission Vital Signs

i. BP (right arm, sitting) – 140/90; T – 37.6; HR - 104; RR – 36 on 2l/min via

nasal prongs, O2 sat - 90%,

ii. She has been having pain in her tailbone since the fall. Pain at rest 7,

pain with activity 9.

Height/weight and malnutrition screening

i. She is 165cm and 45kg. She says she has lost about 10 kg over the last 4

to 5 months and is eating less than usual in the last 3 weeks

Functional Status (ADL, diet, toileting etc.)

i. Uses a cane, is continent, previously independent with ADL

Personal/Family Situation;

i. Mrs. Jones relies on help from neighbours, lives in a two story home

Alert for Behavioural Care

i. During your assessment Mrs. Jones was uncooperative and not following

instructions

DOCUMENTING A NOTE (PAGES 31-35)

3. Document your admission note

LINKING A NOTE TO AN ASSESSMENT (PAGES 38-39)

4. At 0900, the patient had a fall in the room. The patient is found on the floor with no

apparent injuries. The patient is put back to bed, the bed alarm is activated and 3 side

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rails put up. Document a Gen Incident Log intervention and link a fall note to the

intervention.

WORKLIST MANAGEMENT/CARE PLANNING (PAGES 25-30)

5. Change the frequency of the vital sign assessment to q4h (refer to page 7).

6. Complete the Admission assessment from the worklist.

7. Add the GEN Fall Post Monitoring assessment added to the worklist

8. You were unable to do the vital sign assessment because the patient was out of the

room, remove the clocks for the vital sign assessment.

CORRECTING INTERVENTION DOCUMENTATION (PAGES 19-24)

9. Review the admission assessment, notice that the temperature was incorrectly recorded

as 37.6 instead of 36.7, make the correction to the assessment.

CORRECTING A NOTE (PAGES 36-37)

10. Upon review of the Fall note it is seen that 3 side rails were put up but it was really 2.

Amend the note to correct the documentation.

ALLERGY AND HOME MEDICATION DOCUMENTATION (PAGES 43-54)

11. The patient’s POA has allergy information which need to be entered Allergies:

Shell Fish

Penicillins

12. The POA has also bought in a current list of home medications from the patient’s pharmacy. These meds were last taken 2 days ago.

Lasix 40 mg PO Daily

Insulin NPH 10 units in AM and 5 units at HS via insulin pen

Metformin 500 mg PO BID (was prescribed as 1000mg PO BID)

Latanoprost 0.005% eye drops 1 drop in left eye qHS

Milk Thistle 250mg daily (HINT; Additional Information”)

Finished 7 day course of Amoxicillin (started eight days ago)

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SPECIAL INDICATORS (Page 42)

13. Add the M-COVID-19 Suspected special indicator. 14. IPAC have cleared the patient as no longer suspected so remove the M-COVID-19

Suspected special indicator

INDIVIDUAL ORDER ENTRY (PAGES 74-79)

15. Enter the orders on the Medicine/Telemetry Admission order set ON THE NEXT 4 PAGES

(note that on this unit the care provider will collect blood specimens themselves and

stool samples are yet to be collected)

Note that some of these orders will be entered as Orders and some on the Gen

Interprofessional Kardex only.

Remember to note on the order sheet whether the order was entered in Order

Management (OM) or onto the Kardex (K)

There are a total of 10 orders to be entered into the Order Management (OM) system

and several orders that must be entered into the GEN Interprofessional Kardex

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EDITING DIET ORDERS (PAGES 91-95)

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CHANGING DIET ORDERS

16. Change the diet order to diabetic diet, honey thick liquids, minced texture and Resource

2.0 Honey with each meal.

17. Change the diet order to enteral feed, Iso-source 1.5 at 50mL per hour for 24 hours

ENTERING MEDICAL DIRECTIVES AND OBTAINING SPECIMENS

18. You implement a medical directive for MRSA/VRE cultures as the patient was at another

hospital in the last month. Enter the orders for this medical directive using the

Multidrug Resistant Organism Screen order set. (You have not yet collected these

samples)

ORDERS AND THE WORKLIST (PAGES 95-96)

19. The patient has now had a bowel movement and the stool sample was taken. Return to

the worklist and document the collection of the stool sample and the MRO swabs

ACKNOWLEDGE ORDERS (PAGES 96-97)

20. Acknowledge the orders entered and sign off the order to indicate that the orders have

been verified.

EDITING/CANCELING ORDERS (PAGES 81-86)

21. The CBC is really for tomorrow, change the start date and time.

22. The physician no longer wants the CXR, cancel this order

23. Edit the clinical history of the MRI order and enter previous breast cancer

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BONUS ACTIVITIES (only complete if you have completed and are comfortable with all

previous activities)

24. Document another intervention; Document the IPAC Nursing Precautions as Routine

25. Home medications; A letter from the patient’s family physician has now been faxed to

the unit. Update the home medications to reflect the changes below:

Insulin NPH 14 units in AM and 10 units at HS via insulin pen

Flovent 125 mcg 1 puff (HFA) INH BID

Fentanyl 75 mcg patch q72h 26. End of shift documentation;

Document your GEN Shift Handover intervention.

Preview the “Nursing Worksheet by Name” for your patient