department of nursing computer class block b … · department of nursing computer class block b...

Department of Nursing Computer Class Block B

Class Prep • Verify orders are DC’d on POC with the exception of Admission Orders Sets,

these will be used for future classes. • Check that the flowsheets entries have been purged from previous classes. • Up to four days prior to class Order from Physician Log on MES Classroom

(\Nursing\NursingOrientationBlockB\MES Classroom Order set.ppt Order set) If the Order Set is not available, contact. < [email protected] >

• System will automatically purge MES Order sets after 5 days) • Introduce yourself to NES. There are two NES, RN scheduled for each session,

and available to answer nursing related question and to assist individuals through the class as needed.

• At times there will be an ED Nurse in Orientation, their home screen is different. Please offer that they may follow along using their assigned home screen or provide them with a TR account. The NES for ED will schedule them for Block A and Block B (FS only) and they will not attend Block C.

• Distribute Reserve Signs (located in bucket) back rows for those wanting independent study

• System Accounts if needed TR 56-60 • (Do not share system passwords w/students) • Use List Group MES Training • RN 1 - Generose • RN 2 - Charter House • Turning Point is used during this session please contact Kayone or Denise Foy if

you need additional instructions. Often the mes

Handouts/Scenarios Located in TUBS provided by nursing. The tubs will be delivered to the classroom with the materials. There are three tubs, one resides in the Generose Classrooms, the others are sent via general service to Charter or OC. Inside the two tubs that are delivered have a copy of each set of test numbers for RN2 and PCA/US list. This way no matter which bucket is marked to be delivered you will have access to the correct test numbers. 1. Flowsheet Practice Scenario 2. Plan of Care Scenario 3. Patient Education Scenario

PPT Located in Block A folder ..\NursingOrientationBlockA\RN 2010.ppt

Custodian (checklist) Kayone

Custodian (QR) N/A

C:\Documents and Settings\mal07\Local Settings\Temporary Internet Files\OLK1\ChecklistBlockBrevised.doc Revision 1-3-2011 krm

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CONCEPT Detail

LOG ON Log on using Ctrl+Alt+Delete

SET ORDER PROFILE VIEW PREFERENCE

Launch MIC LW Production (May complete at end of class as well) • Order Order Entry Inpatient • Electronic nurse order • Order list tab • Click Personal view radio button • Click Display options. • Category filter in • Cares Physician to nursing order • Nursing Nursing Orders • Con Consults • Save as My default

LAUNCH TR • Launch MICS TR

• Activate Assigned Patient

OFFER INDEPENDENT STUDY

Independent Study • Explain the importance of using MICS LW Training, otherwise will be charting

in Production on a real patient. • Instructor Note: Students may have previous experience here at Mayo.

Examples might be PCAs, Summer III Students, or completed a Capstone Program. For those individuals they may choose to complete the Flowsheet and Plan of Care Scenarios instead of instructor lead and then work on MANDATORY ONLINE TRAINING courses.

• Provide them the option of following along during the POC, recent changes on December 9th.

NURSES ASSIGNED TO PCU ICU OR ED

Ask how many will be going to the PCU/ICU/ED? • Share with the PCU/ICU nurses that this is generic training and provides basic

navigation for flowsheets and they will use the Critical Care Flowsheets and also prepare them in the event they need to float to a general care area.

• ED Nurse do not float and have home screen is different. Please offer that they may follow along using their assigned home screen or provide them with a TR account. The NES for ED will schedule them for Block A and Block B (FS only) and they will not attend Block C.

FLOWSHEETS Flowsheets

Background: FLOWSHEETS are spreadsheets with pre-configured rows used for documenting patient assessments. Below are the flowsheets we will complete the documentation for our test patient. • Vital Signs,


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• General Care Assessments, • I&O: • Point out the other flowsheets from the chart tab, currently there are 45 different

flowsheets, being used for patient documentation in both inpatient and outpatient settings.

Vital Signs Flowsheet

VITAL SIGNS FLOWSHEET EXPLAIN SCREEN

Vital Signs Flowsheets • Vital signs are completed at admission and typically 2x per day or as determined

by the unit. RN, LPN and PCA will document in this flowsheet. • Select [Flowsheets] [Vital Signs] • Explain screen • Organized in Rows and Columns • When charting the system allows movement only one way top to bottom • System does not allow you to chart in the future or after initial time column has

been set • Pause over buttons for fly by help • Add Column ( Chart new results) • Update (Update highlighted results) • Change Time (Change date time for selected column) • Display Details (Display details of highlighted or charted results) • Change Display (Change time/frame units of display) • Column, Older • Column Newer • Support Team Use ( grayed out) • Nursing Order Entry (mention only will learn in block C Nursing Order Entry) • OutMEDLIST (mention only training will be by preceptor used to capture the

list of meds) • Print FS (to initiate printing) • Charted FS(Display list of charted flowsheet for this patient) • Cancel • Explain, Check this box to show data for the F/S only, and includes a

corresponding “OK” button. • Note: Templating, inpatient rows template for 3 days and outpatient template as

long as the are displayed on the flowsheet screen. Calculated rows can be deleted from the display detail screen, but the auto trail does not show

SCENARIO 1 Record admission Vital signs on flowsheets for patient.

ADD COLUMN • Click Add Column • Verify Provider name, mention bug in system sometimes previous user still

logged in. • Date and Time (Military) can be adjusted to reflect the actual time vitals were

completed


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.

Summary Note:

• System bypasses this row, can add column and return to cell if needing to enter data.

• You may use summary note within any flowsheet we will practice adding a summary note in the General Assessment Flowsheet.

Temperature (C) 38 Mention comments section is not usually needed in the vital flowsheet

Temperature Site Skip Row Note: Oral is standard and chart only if not taking oral temperature. .

Pulse Rate(beats/min) 90 Note: Use this row to chart radial pulse

Heart Rate (beat/min) Skip Row Note: This row would be used to chart an apical pulse.

Heart Rhythm Regular

Systolic BP 110 Rows displayed together; updating only one row required

Diastolic BP 85 Mention: BPs at the same time, such as right and left arm record second reading in the comment field. Introduce arrow keys, tab or enter keys work as well.

MAP Mean Arterial Pressure

Skip Row Instructor Note: Mean arterial pressure (MAP) is a row for diastolic pressure on the general care Vital Sign Flowsheet and for the ED so that nurses in general care and in the ED have a place to document MAP in those certain situations where nurses want to monitor trends in MAP. It is there as an option to fill in when it is assessed (such as a patient with possible sepsis) but not a mandatory piece of assessment information with routine vital signs.

Position/Cuff Students Choice Mention: Used for orthostatic BP, (pt lying down and then standing) Need to add column and chart results for Systolic, Diastolic and position of cuff.

Respiratory Rate/min (min)

18

Respiratory Pattern Students Choice

Respiratory Effort Students Choice

Oxygen Therapy Skip Row

Oxygen Amount Skip Row

SP02 (O2 Saturations) 90 Explain: larger Comment Section

Modified RASS Modified RASS, (Richmond Agitation Sedation Scale) 0/AlrtCalm


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CVP (mmHg) Skip Row Note:CVP (Central Venous Pressure) is a requested row for certain units. They are very familiar with this concept. Normal CVP readings are between 3-11 mmHg.

Height (cm) 166 cm

Weight Admission (kg)

60 kg Explain the importance of using this cell for admission weight only .If the weight cell is used instead of admission weight cell, the system will cross reference any previous admission weight entered and will calculate the weight changes based on this information which may be outdated. This also includes shared admission weight rows between flowsheets and the data interfaced from chart+.

BMI System0 bypasses calculation rows Note: system automatically calculates and displays value when the height and weight is charted. BMI Calculated rows will be deleted when the Height/Weight is deleted.

BSA System bypasses Note: system automatically calculates and displays value when the height and weight is charted. BSA Calculated rows will be deleted when the Height/Weight is deleted.

Weight (kg) Skip Row Note: This row should be used for daily weight checks.

Weight Change Admit (kg)

System bypasses calculation rows Note: system automatically calculates and displays value when the admission weight and weight have been charted. See upcoming example

Head Circum Skip row

Vitals Signs Other

Skip Note: Generic row can be used as needed. Example might be for arterial brachial index

CHARTING DAILY WEIGHTS

• Pre-select two of the weight cells • Weight • Weight Change Admit

• Selecting the two rows allows the system to calculate the weight change • Click Add Column • Enter current weight of 63 • Click OK • Show the weight change calculation • Instructor Note: From Display detail screen, allows calculation to be deleted

manually. • Note: the weight change will calculate by crosschecking the last entered

admission weight compared to the weight row. Instructor Note: the weight change is the information that is needed by the providers and nursing staff for the care of the patient.

OWN THEIR OWN • Have student chart entries in new column


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CORRECTING CHARTING ERRORS

Correcting Charting Errors • Click in Temperature Cell • Click Update Button • Enter Temperature 37 • Click Update • How would we review previous entries? • Display Details.

DELETE CHARTING Delete Charting Errors • Click in Respiration Cell • System allows you to double click in a cell to open the window, if double

clicking verify it is the correct row, occasionally the wrong row is displayed • Explain how systems displays appropriate action buttons • Click Delete Button • Explain Audit Trail

CHANGE TIME FOR ONE ENTRY

Change time for one cell • Highlight temp cell • Click Change Time button • Modify time to match a existing column • Click OK • Show how the cell moved to selected column

CHANGE DATE AND TIME OF COLUMN

Change Date and Time of Column • Highlight Column • Click Change Time button • Modify enter previous military time • Click OK

DELETE A COLUMN Columns can not be deleted • Have students try to delete column • Explain once date/time stamped unable to delete column only entries

VIEWER Summarized Viewer • Ask where would we navigate to see summary view • Patient Data Views/Vital Sign Graph

PPT SLIDES REVIEW Using Turning Point Review Slides

General Assessments

INTRODUCE GENERAL ASSESSMENTS

General Assessment • RN completes a multi-system assessment x2 generally at 0800 and 1300. The

LPN will not be responsible for assessing or documenting the multi-systems findings, but will chart in other sections of the flowsheets, Have the LPN follow C:\Documents and Settings\mal07\Local Settings\Temporary Internet Files\OLK1\ChecklistBlockBrevised.doc

Revision 1-3-2011 krm of 30

the example in class today, but let them know the first section is documented by RN only.

EXPLAIN SCREENS Access General Assessment Flowsheet

• Select [Flowsheets] [General Assessments] • Explain the multi section flowsheet • Red represents the section that is activated. Have students review the section

and take note how the rows change to reflect the activated section • Scrolling left and right to view all sections • Can’t chart in the future or change to future time after the initial time column has

been set • In certain rows data may template forward, however comment will not and will

need to be added. • When not met or met is charted it will forward to the corresponding section. • Expand and Collapse • Mention buttons along the bottom of the screen, similar to those in vitals

flowsheet,

EXPLAIN SECTIONS General Assessments Section Descriptions/Purpose • Have students explore the different sections • Assessment Criteria; 2x per day RN section only • Pain; Pain Assessment • Skin General; General skin assessments and also Braden Skin Scores • Skin Alterations; actual alterations • Skin Alterations 5-8; for additional alteration, Incisions are charted in that

specific sections • Tissue Perfusion; A term that describes bloodflow into the tissues, chart edema,

antiembolic stockings • Pulse/Neurovascular; direct physician order, the pulse and neurovascular

assessment. • Respiratory Gen; Assessing lung sounds and treatments • Chest Tubes, documenting site and status, does not have rows that carry over • Sens Percptual Gen; Mental Status • Activy/Home; Activity/Mobility ambulate, Health/Home Cares • Anx-Coping Saftey Anxiety, safety • Nutritions/Elim Gen; Diet, elimination, indwelling catheters • Intravas Device; IV, start date, rate, type and location • Invasive Sites; Type, location, dressing changes • Incisions; location, dressing status, skin alteration should not be used for

incisions • Drains 1-6; Location, site, status • Drains 7-12 • Ostomy location, type and condition of the urinary or digestive tract surgical

opening


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SCENARIO 1 Scenario 1: Completed initial assessment on new admit and ready to chart.

ASSESSMENT CRITERIA

Select Assessment Criteria • Click AddColumn • Explain column added for each section

SUMMARY NOTE • Will chart later

MULTI SYSTEM ASSESS Category only expand collapse rows

SKIN ASSESSMENT Not Met

TISSUE PERF ASSESS Not Met

RESPIRATORY ASSESS Not Met

SENS PERCEPT ASSESS Met

ACTIV/MOBIL ASSESS Not Met

ANXIETY/COPE Met

SAFETY ASSESSMENT Met

HEALTH/HOME ASSESS

Met

NUTRI/FLUID ASSESS Met

ELIM//OUTPUT ASSESS Met

SCENARIO 2 Scenario 2; We need to complete charting in the Pain Section

PAIN SECTION EXPLAIN ROW EXPLAIN OTHER FLW

• Select Pain Section • Notice the column is already present • Explain filters to view charting from other F/S and this F/S only. • Explain Other flow Modified

ADULT NONVERBAL PAIN

• Scroll Down to view this section • Adutlnonverbal pain • Mention Only

ADULTBHVRPAINSCALE

AdultBhvrPainScale • Mention Only

• Face (Expression) • Activity (Movement) • Vital Sign Changes • Total ABPS Score


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• All rows pertaining to ABPS display in one window.. We will see another example like this in the Skin Section

• Instructor Note: ABPS is an acronym for Adult Behavioral Pain Scale. Nurses will know this term.

FLACC PAIN SCALE

FLACC Pain Scale • Mention Only

• Face • Legs • Activity • Cry • Consolability • Total FLACC Score

Note: used by RN for patient that can’t rate their own pain, Rns may not be familiar with this. All rows pertaining to FLACC display in one window.. We will see another example like this in the Skin Section

• Scroll to top row PAIN #1 • Category only expand collapse rows

• Pain Assessment, documented from Assessment Criteria • Instructor Note:

• Modified RASS, explain other flw, (Richmond Agitation Sedation Scale) will be used in the final scenario

PRE-SELECT ROWS FOR CHARTING

• Pre-select the following cells

• Click Update

PAIN #1 LOCATION Shoulder R

NUMERIC Pain Scale #1

4

PAIN COMFORT GOAL Students Choice 2

FACE PAIN SCALE #1 Skip

PAIN #1 DESCRIPTORS Incisional

PAIN #1 DURATION Use Modifier row, click hour Results 2 (used to determine chronic or acute pain) Show/Explain added modifier rows Note: Certain rows have modifiers when it is necessary to use a modifier, select from the drop down Menu. If charting continues in the modified rows it will remain on the flowsheet., otherwise it will fall off after 8 columns have been added. If the cell is deleted the modified row will also be deleted

PAIN #1 FREQUENCY Intermittent (comment increases when taking deep breath)


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PAIN #1 PHARMLINTERV

Medicated (type ME to show filter)

PAIN #1 NONPHARMINTERV

Reposition

ON THEIR OWN On their own complete the detailed charting in the Pain Section # 2

PAIN #2 Category only expand collapse rows

PAIN #2 LOCATION Instructor Example Back + Spine

NUMERIC PAIN SCALE #2

Instructor Example 2

FACES PAIN SCALE #2 Skip

PAIN #2 DESCRIPTORS Instructor Example Spasm

PAIN #2 DURATION Use Modifier row, click year Results 2 (used to determine chronic or acute pain) Show/Explain added row

PAIN #2 FREQUENCY Instructor Example Intermittent

PAIN #2 PHARMLINTERV

Instructor Example ME

PAIN #2 NONPHARMLINTERV

Instructor Example Heat

VIEW COMMENTS View Comments • Select cell with yellow sticky and click display details • Click Cancel • Mention if reviewing the comments by double clicking on the cell be careful

to use the cancel and not update, it may take on your user Id for that entry • Verify comprehension regarding as why we would click cancel instead of update.

SCENARIO 3 Scenario 3; We need to complete the detailed charting in the Skin General Section

SKIN GENERAL SECTION

Select Skin General

SKIN INTEGRITY GEN Category only expand collapse rows

SKIN ASSESSMENT Not Met copied from the Assessment Criteria Section

BRADEN SKIN SCORE ONE WINDOW FOR ENTERING

• Pre-select the Patient Mobility Cell and click update. • Note: All rows that are contained in the Braden Skin Score will be display in one

window. Score is automatically calculated and also a modified Braden Scale available for peds patients.

• SKINS SENSORY PERCEPTION

Student’s Choice


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SKIN MOISTURE Student’s Choice

PATIENT ACTIVITY Student’s Choice

PATIENT MOBILITY Student’s Choice

PATIENT NUTRITION Student’s Choice

SKIN FRICTION/SHEAR Student’s Choice

BRADEN SKIN SCORE Calculated by the system

SCORE LESS THEN 18 Will review entering Nursing Diagnosis later today

NOTE MODIBRADENQ SCALE

(for Pediatric documentation)

MODIFY/EDIT BRADEN SCORE

Update Braden Skin Score • Select one of the cells • Click Update • Make a change to the row items • Click OK Note: score automatically calculate changes to the score

CHANGE TIME OF COLUMN

Change Time of Column • Select the column Heading • Click on Change Time Button • Explain advisory window: • You are changing the time of this column. Should this apply to the entire

flowsheet or just this section? • Yes> change time for this column within the entire flowsheet. • No> Change time for this section only

• Select Yes in the advisory window Note: If you set the new time to the same time as an existing column with data, it will say you can’t overlay this entire column onto an existing column. You may move one section at a time.

SCENARIO 4 Scenario 4; Need to indicate the patient has an Indwelling Catheter.

NUTRITION ELIMINATION SECTION

Select Nutrition Elimination

URINARY CATH SATUS • Click on the Urinary Cath Satus • Click Update button • Modifier: Indwelling • Result Urinary Catheter in and Patent • Note: the new row appears on the screen, volumes are charted in I&O


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SCENARIO 5 Scenario 5: We need to chart the D5-0.45 normal saline was started.

INTRAVAS DEVICE NORMAL SALINE

Chart D5-0.45 Normal Saline was started. • Select Intravas Device • Pre-select rows

• IV Rate • Int Dev# 1 insert Date • Int Dev #1 Location • Int Dev#1 Type

• Click Update Button

IV RATE MODIFIER • IV Rate • Modifier D5-0.45NS – D5W and 0.45% NaCl

• Displays in Modifier field as D5-0.45NS • Result 80 Note: The volumes for LVP’s (Large Volume Parenteral fluids) will be charted in the I&O Note:

INT DEV# 1 DATE • Type 0D Note: F1 to display help and explains relative times.

INT DEV #1 LOCATION INT DEV #1 TYPE

• Student’s Choice

• Student’s Choice • Instructor Note: Type PIV is a suggested choice by NES staff

SCENARIO 5 A Later in the day you note the patient hand is swelling near the peripheral IV site and the area is cool to touch, we would want to document this in a summary note.”

EXPLAIN THE USE OF A SUMMARY NOTE

The purpose of a summary note (nurses note, taught in nurses training)is to have pertinent patient information viewable for the multi-disciplinary team. Summary notes are available to use in any flowsheet, When charting the viewer will display nursing note along with entries within that flowsheet/and or section of flowsheet. Appropriate use of Summary Notes includes: • Patient status change

e.g. sepsis (any or all of the following): fever, tachycardia, tachypnea, increasing oxygenation requirements; including orders or interventions from calls to service

• Patient Fall include outcomes, interventions, call to notify Service

• Potential or actual aspiration include call to notify service and orders/interventions

• Complex discharge information • Transfer to test or procedure or a procedural note.


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ENTER SUMMARY NOTE

• Click Summary Note • Update • Copy from Summary Note mention only, pulls copy of prior notes • Instructor Note: If asked Copy from Summary Note, is not used routinely,

would pull in last note. If no previous note button will not display. • Enter Note Editor

• Type Note: “5x8 cm swelling noted on left hand near peripheral IV site. Area cool to touch. Service Notified. Will continue to assess.”

• F12 • Click Save • Instructor Note: System does not allow the pre-select of summary note and then

add column. Column needs to added, then click summary note and click update.

VIEW SUMMARY NOTE • From Patient Data View • Notes • Filter to Flow sheet Note • Instructor note will also see the Flowsheet entries from this section as well.

SCENARIO 6 Scenario 6; IV rate has changed and need to chart insulin on the med infusion row

INTERVAS DEVICE

Select Intravas Device Section • Pre-select cells

• D5-00.45 • Med Inf Dose

• Click Add Column Button

D5-0.45 RATE CHANGE • D5.045 • Result change to 125

MED INF DOSE (INSULIN)

• Modifier Insulin • Result 2 Note: The numeric value entered represents units. The word Units not needed

MEDICATION ADMIN RECORD

View MAR • [Medication] [ Medication Admin Record] • displays insulin, also will chart volumes in I/O and administered in medication

worklist PATIENT DATA VIEW

• Patient Data View • General Assessment flowsheet are not accessible through a chart tab they can be

displayed by setting up a My Favorite • My Favorite Viewer 1 was set in session A, for the General Assessment Viewer

production

PPT SLIDES REVIEW Using Turning Point Review Slides


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I/O Flowsheet

I & O FLOWSHEET

[Flowsheet] [Intake Output]

CHANGE FACILITY Change Facility button-Used to switch the facility from one location to another in order to utilize tasks in MICS LW • Home screen • Click Change Facility • Double Click Location • OK • Instructor Note, if you access I&O flowsheet status bar will display message No

applicable account found.

EXPLAIN SCREENS I & O Flowsheet This flowsheet is where Volume and Counts are documented. Columns are pre-defined with times, and the screen displays daily total and three day totals. All values are entered in ml (milliliter) with the exception of counts. The row labels are organized as follows: Fluids In

• GI intake • Oral (fluids taken by mouth) • Crystalloids • IV fluids large volume IV, intermittent fluids • Colloids • For blood products (RBC)

Fluids Out • Urine • (Urine voided)

GI • Stool • Emesis

Drains • i.e. Jackson Pratt Chest Tubes :

Explain Scroll Arrows and Through Date Scroll arrows are located at the bottom of the screen if it is grayed out, the through date may have been changed, and would need to change it back the current date (0D) Encourage the use of the viewer to review previously charted results, instead of changing the Through Date. Explain how and why Column Times are labeled and Radio buttons function There is not a 24:00 column for midnight it is shown as 00:01, this is because the daily totaling feature. Time is from 23:59 to 00:01, over the midnight our (won’t see 00:00) Radio button are defaulted to hour increments, this can be switched from 1 to 12 hours, to see a specific time or an entire shift Calculation Rows


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At the bottom of each column, there will be an accumulative running total, calculating from midnight, based on the radio buttons selected above. The far right 3 columns are the daily total for current day and previous 2 days. Charting buttons Point out and we will use them during class

1. User needs to update the entry and manually add the count or volume. 2. Select an earlier column and change time, the system will then calculate. 3. Select the entire row, enter date and time. 4. The Chart Plus rows are placeholders were removed on July 1, 2020

SCENARIO 1 Scenario 1; Patient consumed a glass of water and we need to chart this.

CHARTING ON LABELED ROW

Charting on a labeled row. • [Flowsheet] [Intake Output] • Explain Parent Rows • Select current time cell in Oral row • Click Add/Update Entry • Result 500 (note charted in ml) • Date/Time: defaults to now • Explain time can be changed but for this example will leave as current time

• Comment field could be used to chart pertinent info. (pt diabetic, part of afternoon snack)

• OK • Notice the entry is now being calculated in the daily totals

SCENARIO 2 Patient consumed another glass of water

MODIFY ENTRY IN SAME COLUMN (SYSTEM TO CALCULATE)

• Select the Oral row • Click Add/Update Entry • Enter amount 400 • Current time displayed we will leave for now but note time can be changed • Note system calculates amounts 900

DELETE • Click Cell with entry wanting to delete Add update entry • Highlight entry needing to remove • Click Delete • Click OK • Click Cancel • Notice the updated calculation in the totals

SCENARIO 3 Scenario 3; Patient had a maintenance bag running and we hung a new bag for the patient ½ hour ago. We need to chart that the previous bag was given.

CHART ON LABELED ROW

Charting on labeled row and update time. • Select correct time cell in IV fluid row • Click Add/Update Entry


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• Result: 1000 • Date/Time: Hover cursor over field to get screen tip • Change time to ½ hour ago • Save

SCENARIO 4 Scenario 4; Patient received a normal Saline Bolus of 1000 2 hours ago and we need to document the volume.

ADD NEW ROW Add New row example • Click Add New Row • Intake/Crystalloid/Bolus • Results 1000 • Verify date/change time • Click OK

SCENARIO 5 Scenario 5; Patient had a loose stool one hour ago and we need to document.

COUNTS Charting a Count Example • Click the correct time cell in the Stool row • Click Add/Update Entry • Result: enter the # of loose stools for this example use 1 • Verify correct date/time • Ok • Note the Blue asterisk indicates this row is a count only, it won’t be calculated

into the daily totals

SCENARIO 6 Scenario 6; Patient had another loose stool and we need to chart it in the same time column.

ADDITIONAL COUNT Charting counts on a labeled rows • Select a Stool Row • Click Add/Update Entry • Enter 1 • Enter correct Date/Time • Click OK

SCENARIO 7 Scenario 7; Patient has an indwelling catheter and we need to document an output of 400.

NEW ROW OUTPUT Adding a New row for OUTPUT • Click Add New Row • there are more options to follow that selection • Double click Output • Double click Urine • Select Indwelling Catheter • OK • Result: 400 • Save


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• Ask students where they would document color or urine? • Other factors such as color would be documented in General Assessment, Note: The same row can’t be added twice (like in Chart+). If some tries to add a 2nd row the system would add the total to the already added row.

SCENARIO 8 A dietary supplement was given to the patient and they consumed the entire contents of the container and we need to document 240 ml were consumed

NEW ROW INTAKE Adding a new row for INTAKE • Click Add New Row • Double click Intake • Double click GI • Select Supplement • OK • Result: 240 • Verify correct Date/Time • OK Note: If charting is missing, go out and back into I&O to refresh screen. Charting should then appear. If charting happened while the computer time clock changed over an hour increment, info may have started to be entered in one hour but by the time it was completed, time elapsed in the next hour column.

SCENARIO 9 Our patient has 2 Jackson Pratts and we need to document output for each

MODIFIER Adding Rows by using a Modifier, • Note: Using modifiers is the only time we will not choose Add New Row to add

a row • Click in appropriate time cell in Parent Drain Row (not yellow folder) • Click Add/Update Entry • Modifier: jax Pratt #1 • Result: 75 • Verify Date/Time • OK • Have student repeat steps for second Jackson Pratt • Note: When charting a row using a modifier this is the only time we will not

choose Add New Row if not charted on for 3 days will drop off.

AUDIT TRAIL Audit Trail Select Urine row(s) and choose Display Details

PATIENT DATA VIEW Summarized Viewer [Patient Data View] [Vitals/Intake Output]

TURNING POINT SLIDES 10-12

Review of I&O

PRINTING

If ask, it is discouraged they can speak with preceptor

PRACTICE SCENARIO • Flowsheet Practice Scenario located in blue tub • If running short on time, this scenario is optional


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PLAN OF CARE • The Plan of Care is a communication tool that incorporates nursing assessment, diagnosis and interventions/education with physicians’ orders to provide an individualized and organized plan of care for the patient.

• You will use it to review the current orders, admission information on your patient, view nursing diagnoses and nursing care planning orders.

• You will have the ability to create a printout of the orders for your patient/patients to use as a reminder throughout the day.

• Plan of Care

CHART ON POC FLOWSHEETS ECODES

• You’ve visited with the patient and family and we need to add/update information on the Kardex.

• With test Patient Activated. • Plan of Care • Access the Kardex (upper right of screen) by clicking anywhere in the

flowsheet. • Unlike other flowsheets, information added to the Kardex within the Plan of

Care should be recorded in just one column per hospital admission. In other flowsheets you would begin a new column for a new event, but in the Kardex we always need to add to one single column.

• Instructor Note: If you added another column the first is not viewable immediately on the POC screen. (Misleading) It may also cause confusion in the Kardex viewer if previous column does not display because the go-back days defaults to 7.

• In class we will be adding a column, but you would add a column ONLY the first time.

• Click Contact Person cell • Click Add Column • Click OK to accept Date, Time, Provider • Contact Person • indicates required field • Result – yes • Enter Editor Note (use ecode – this is the first time introduced) • Ecode stands for expansion code and is a shortcut to typing information. It

works like a template in this example. • /contactx + F11 to activate ecode • Enter contact information (spouse’s name, motel) Instructor Note: POC

Scenario states to update contact person, from spouse to daughter. • Keyboard ↓ can be used to navigate from line to line. • F12 to exit note field • *Provider –verify that this displays your name. • Save • Post –it note indicates …note or comment


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• Note: Cannot start a Kardex flowsheet from the Flowsheets chart tab • Buttons (review from Block A class – Mention Only) • Add Column – for Kardex, only add column if one has not been started. • Update – select the cell and update the information in that row. • Change Time – allows you to adjust the time on your column into the past. • Display Details – click on this to show details/revisions on all rows. • Other buttons – are used for other flowsheets. • Click Cancel to POC screen • Instructor Note: • Surgical Procedures row is present on first view, and once clicking on flow

sheet to make entries the row has been updated to HospCourse/Procedure, no need to mention to class unless they question. (8-15-07)

POC LINKED VIEW • To get an overview of your patient, choose the POC-Linked View button

• Notice the multidisciplinary notes back to admission, documentation from the active Flowsheet for this patient, and active orders.

• You can select buttons such as Intravascular Devices to see Flowsheet data and orders for IVs.

• You can chart within the Flowsheets (Go to or double click) • You can see Order Detail and Order Profile. You can add orders.

• If you have had this screen up for a while, you can refresh to see any new orders that have been placed since you came to this screen.

RN REVIEW • From Show Orders Profiles On the PPOC Linked View Screen • Order Profile – Inpatient • Order View, generally is set to Orderset/Protocols Order View • Click Prescriber/Provider to filter to view physicians to nursing orders (non

medication orders) • The orders will appear in reverse chronological order, or simply the most

recent at the top of list • Teal highlighted orders are new Physician to Nursing Cares Orders that need

to be reviewed by the RN. • Nursing Cares orders that have not been acknowledged will also be

highlighted in teal. • Notice how the buttons are aligned and there are two associated buttons at the

bottom of the screen o RN Review o Order Check

• To acknowledge in the paper order book, there is a black line process for new orders in the electronic version we will select teal orders, if more then one order you may click and drag.

• Important to Review Detail of order o Resize Column is an option if no ellipses (...) appear the entire

comment is available. o After Resizing ellipses (...) are still viewable o Select Order


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o Click Review Detail, or double click o Cancel

• Select the first teal order and Press drag all teal orders o To deselect Order hold Ctrl key

• Click RN Review • Welcome, use E mode • Continue • Once RN Review button is clicked, the order is no longer highlighted teal it

has been acknowledged. • Don’t highlight if disagree and order is not appropriate for your patient

contact the service to have the order discontinued • Physican screens have an “Acknldge” column a value of “Y” indicates the

order needs to be acknowledged by a nurse. When a nurse acknowledges the order the “Y” no longer displays in this column.

• Instructor Note: There is no visible auto trail available for users, for orders that have been reviewed by the RN, programmers can provide information if needed for legal reasons.

ORDER CHECK COMPLETION

• From Order Profile • Click Order Check • E mode • Continue • Defaults to Order Check Completion Tab • Reverse Chronological Order (most recent order appears at the top of the list).

Displays both active/cancel orders • Reference Information regarding Order Check Completion Process

o The oncoming RN checks all orders that were reviewed and signed by the RN from previous shift. (all the way to previous red line)

• Scroll to review orders, may have more then one page • Click Check Complete • Order Check Completion added to top of list • Note the Indentation and Center alignment to have Order Check Completion

line item easy to locate. • Note: RN Review can be completed from this screen as well. • DC Orders will remain teal and will also need to be reviewed. • Click Order List, RN Review button, explain from profile, order lists and

Completion Screen RN Review button is available.

DOCUMENT THE CARE PLAN BY PLACING ORDER FOR NURSING INTERVENTIONS WELCOME SCREEN

• You have assessed your patient and you are ready to document your care plan.

• Access the Nursing Order Entry Screen • Use same assigned patient • Click Enter Orders • Order Entry – Inpatient • RN Electronic/Written (Free Text) C:\Documents and Settings\mal07\Local Settings\Temporary Internet Files\OLK1\ChecklistBlockBrevised.doc


• Review descriptions for various modes • RN: Electronic (E)-orders initiated under a nurse’s licensure. Example

of electronic order: Care planning interventions, protocols, Non-MD consults

• Wrtten Free Text: Written (W)-orders entered from a paper order or free text order printout. No printout is generated. Used for discontinuing orders that does not need a printout. Example of written orders: Free text orders for non-med orders, paper orders and order sets

• Verbal Orders: Verbal (V)-orders entered via a phone call from prescriber in an emergent situation and need signature in 24 hours. Example of verbal orders: medications and treatments such as diet orders

• Specialty Beds/MD Consults • Supervised Ordering: Will not be authorized use • Choose RN Electronic/Written (Free Text) • – Double click E – Must choose one option • Continue

SCREEN OVERVIEW • Brief overview of screen components

• Patient Problem List: List of patient problems primarily from outpatient billing.

• Chart Tabs: Groupings of orderable items. E.g. : Categories, Patient Education, etc.

• Unissued Patient Orders: Selected orders appear here until issued. SELECT NURSING INTERVENTIONS

• Entering a Care Plan • Our patient has a skin tear, and we need to add impaired skin integrity

to the patient’s order list. • (Mention LPN’s won’t be documenting care plans but they may follow

along in this class). • The screen name says Orders – Categories. This is one of the tabs in the

bottom portion of the screen, and allows us to select orders from 16 different categories.

• Ordered By: Displays the provider ordering (YOU). • Ordering Mode: Electronic-Nurse orders: Always check this. • We’ll use the lower half of screen to locate our orders. • Buttons are used to select the order and we will be adding the order details. • Categories Tab – We will select the interventions or care plans that are

associated with our diagnosis. • Click Skin Integrity • Care Plans • Select Impaired Skin Integrity from the Order Selections window. • Order Set Selection window • We are presented with a group of interventions/care plans based on the

diagnosis you selected • Confirm the correct selection: Impaired Skin Integrity C:\Documents and Settings\mal07\Local Settings\Temporary Internet Files\OLK1\ChecklistBlockBrevised.doc


• Click Additional Information to show reference information • Guideline Information • Detail • View IE resources • Close IE • Cancel • Click to choose desired interventions • Documenting our desired interventions assists us in meeting JHACO

requirements • We will select our interventions from Assessments/Care Activities • Monitor nutrition or hydration • Note characteristics of any drainage • Continue • Orders-Category screen • Orders appear in the Unissued Patient Orders List: both of these orders

have a prefilled frequency (Ongoing) and do not require additional details so we can issue orders from this section.

• Review Order Description for accuracy • Could edit or delete if desired • Important to Issue Orders: Unissued orders are not viewable by anyone else. • If you leave this screen with Unissued orders you will get a prompt to Issue. • Click Issue Orders.

ORDER LIST VIEW • Let’s review the orders that have just been added

• Order List View/Add to an Order Set • Click Order List tab • Order List is very similar to the Order Profile. • All Active is the Default view (Order Profile – Ordersets is default view) • Order Description: displays Order, frequency, detail • Status: Active • Category: • Nursing: are nursing requested orders • Cares: would be physician requested orders • Others self explanatory • Subcategory: Type of order (e.g. skin, pain, nutrition) • Notes: Displays at least part of the Note Editor field • Start Date/Time • Ordered by: Displays the ordering provider: nurse or physician • Ordered by is called Signature on the POC Order Profile. • Priority: not being used. • Screen sorted by: Order entered or updated most recently is at the top • Change View to Ordersets View • This displays the Nursing Diagnosis grouped with the orders associated with

it in addition to any other Active orders.


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• Double-click Impaired Skin Integrity • The Order Set Selection window displays previously selected orders • Add Reposition • Continue • Order Details for Reposition • On this screen we can add details, review reference information and issue the

order. • Frequency: Q4H • (Will occur every 4 hours based on the start time you put in) • Explain Q4HWA (while awake is every 4 hours but on a set schedule. See

schedule in drop-down list.) • Start Date/Time: 0D • Time: top of next hour (1400)

Interval Schedules (need a start time…… If no start time is entered, the schedule will begin at the exact time the order is issued and will display that time (e.g. 12:23, 14:23, 16:23, etc.); highly recommended to indicate Start time.

• Comment & Note Editor Fields: Can be used to record additional information, will not use for this order. Always use Comment field first.

• Order Information displays required fields, reference information, allergy information, conflicts:

• Required fields: will be listed and will be highlighted in blue (e.g. frequency ) • Conflicts – would be highlighted in red and indicate that you have an Active

duplicate order on this patient. • If you see a scroll bar, scroll down to see complete information. • Signing Information/Action Buttons • Signature: (Ordered by)verify your name • Continue will add this to a list of selected orders • Cancel All not being used. • Cancel would not issue the order or save information. • Click Continue • Note: Pressing Enter activates the Continue button. • This order becomes part of the Impaired Skin Integrity order set but is

Unissued status right now. • Click Issue Orders]. • The Categories, Patient Education, Consults, Verbal Order,

Test/Proc/Care or Search tabs can be used to toggle back to the original view of the Order Entry screen.

VERBAL ORDERS • Verbal Orders – MENTION ONLY • Scenario: Physician is off-campus or off the floor but needs to enter an

order for a patient. If he/she is unable to enter the order electronically him/herself they may call and give you a verbal order over the phone.


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• An MANDATORY ONLINE TRAINING course has been assigned for Verbal Orders. Mention for navigation only:

• Orders Chart tab • Order Entry – Inpatient • Verbal Mode • Be sure to enter the physician/prescriber name that is giving the order via the

phone in the signature field on the Welcome Screen in V – Verbal mode to ensure it goes to the correct Physician’s Inbox for their signature

• Cancel in class • Caution Nursing on the importance of rechecking what Mode is selected for

ordering. If the mode is not change from Verbal the Service Receives an Inbox message that does not require a signature. Common Error!

ADVANCE DIET

Explain “Advance Diet as Tolerated.” patient can progress to a General Diet,

EDIT REPLACE BUTTON

Advance the Patient diet to full liquids • Order Profile • Filter by Diet • Select Diet Clear Liquid Ongoing • Click Edit/Replace • Texture drop down select Full Liquid • Click Continue • Explain Clear Liquid Sub Status Canceled.

FREE TEXT ORDERS PPT SLIDES 31-37

• All non-med nursing-related Free Text Orders need to be entered into Nursing Order Entry (e.g. diet, activity, vital signs, call service).

ISOLATION ORDER ON YOUR OWN

• Your Patient informed you they have pneumonia and we need to initiate the isolation order. On your own place the order.

• [Order] [Order Inpatient] • Safety Patient Isolation • Droplet • Check the Guideline • Detail • Issue Order • Verify on Order List • Instructor’s Choice review steps with class to check for comprehension.

UNIT ORDER SETS • Search for Unit Order Sets

• Many units have pre-written orders on their paper POC, common non-med orders or “Admission Orders” that would be typical orders for patients in that area. Order sets have been created that group these common orders together. It makes it faster to select multiple orders at once. These orders would not be associated with a nursing diagnosis.

• Orders sets can be found using the search feature. • Click Search tab C:\Documents and Settings\mal07\Local Settings\Temporary Internet Files\OLK1\ChecklistBlockBrevised.doc


• Naming standard • All unit order sets can be found by typing POC • Type poc • I can not see Vascular ICU order set. Up to 50 order sets will appear in

this window. Use scroll bars to navigate to additional order sets –or-

• Use 2 word search string to narrow the search. E.g. poc vascular • Search for and select POC Vascular ICU/ICA(Part A) • Listed alphabetically by POC categories.

Within each category single orders are also listed alphabetically. • You would choose the appropriate orders for the patient. • Cancel • When you are finished entering orders • CLICK HOME: When finished entering orders it is critical to click Home.

This will end your current session of orders.

POWERPOINT OR DEMO OPEN ORDERS

• If you log off before clicking Home the order session will remain open. • Open order sessions will result with an Inbox message –and- • User will not get the Welcome Screen the next time Nursing Order Entry is

accessed. • You will see an Inbox message for Orders – Open


• Review Plan of Care

MINI POC SCENARIO • MES instructor: Give students 15 minutes to work on scenario. Collect these at the end of class.

• Home PRINT TO-DO LIST • You would like to print your “to-do list” for an individual patient.

• Activate Patient • Navigate to POC screen • Click Print To-Do List: You may want to print this list of orders to help

organize your day. • Select Shift Times (time range) for printing. • or type a Time Interval. • The maximum is 12 hours • Select Orders to Print: PFE and/or Plan of Care Orders • Entire Hotlist: This is used for printing on multiple patients. (Confirmed by

Linda G 2-1-09) • Cancel (in class)

SHOW SAMPLE OR PPT SLIDE

• Printout displays current orders for this patient. • Note: Meds were not approved for printing on the worklist. You must review

the meds online. You can write in the meds yourself if you prefer.


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WORKLIST FOR MULTIPLE PATIENTS

• Worklist for Multiple Patients (Could demo this or hands on) • If you wanted to print the worklist for all the patients you are caring for

you can access it using a Hotlist. • The Hotlist on your homescreen can hold up to 48 patients. You can add a

patient one at a time, add all your patients at the beginning of your shift or you could have MICS add every patient you activate to your hotlist. You must use the hotlist if you want to access the worklist for more than just one patient at a time.

• Load patients to hotlist. • Give students 2 or 3 extra clinic numbers and Add Active • View hotlist to see patients have been added.

• Navigate to POC screen

• Click Print To-Do List: • Click Entire Hotlist: This will activate the Current Patient List on your

Home Screen and the printout will include orders for each patient. • The printout will appear with each patient listed in a new cell in the table. • If the Census list is the active list on the home screen it will print the “To Do”

List for all the patients on the census list, which we do NOT want. • Cancel (in class) • To Change Patients • On your next shift you would remove the patients from the hotlist and

add the patients you are caring for that day. • Do this in class!: Select all patients on hotlist and Delete Pt.

RESOLVE A DIAGNOSIS BY DC’ING ORDERS

• Your patient’s skin integrity issues have resolved so we will resolve the diagnosis by DC’ing the orders in the order set.

• Verify your patient is active • We will DC any nursing orders related to the Impaired Skin Integrity. • Navigate to POC screen • Show Orders • Screen is filtered by Order Set View. • Click Impaired Skin Integrity Order set header –or-

Press & Drag to select the patient care orders under Impaired Skin Integrity • DC/Cancel • Welcome Screen • Type E, and Continue • Orders display at top and may be deselected to DC individual orders.

We will DC all at once. • *Discontinue Information • D/C Selected Orders • DC appears if order has been charted on. • Cancel appears if order not charted on. • Exit Profile • Home


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Patient Family Education

PFE ENTRY

When you are completing a care plan for your patient you would also consider your patient’s education care plan. We will choose an education plan as our guide for our patient’s education. There could be additional orders that would be added later to supplement this. Education is implied for all activities or interventions that take place during the patient hospital admission. However, we are required to create an education plan and document the topics covered with the patient, related to their needs once they are dismissed. It is important to complete the charting prior to the patient being dismissed. .

ORDERING EDUCATION PLAN

• Patient Education chart Tab; • Explain the menu options, Order, Worklist, Flowsheet and Viewer • Select Order Entry • Ordering Mode E (Electronic Nurse-Orders) • Continue • Explain same ordering screen as prior however it defaults the Patient

Education tab. • The Patient Education tab has Ed Plans, Ed Materials, Videos and Non-

English within the various categories. Department specific education plans are available by selecting the appropriate button.i.e.

• In class we’ll choose the Generic Education Plan from the generic button.• We will order the Generic Education Care Plan: • Generic • Generic • Ed Plans button • Generic Education Plan • Leave all pre-selected items • Continue • Returned to Order Entry screen • Items appear in the Unissued Orders List: education orders typically do not

require additional order details so we can issues orders from this section. [Issue Orders]

• Orders are now on the Patient Education Worklist as well as Plan of Care & Order List

WORKLIST INCLUDES NEW AND COMPLETED EDUC ORDERS

• To document education and we will use the Patient Family worklist. • Refer to Green Card for Education Process and explain charting terms. • Note: RN’s (not LPNs) will make the assessment on the patient, LPN may

follow along if they choose. • Patient Ed • Patient Ed-Worklist • Worklist Date/Time: Defaults to 15 days of previous education orders. • Instructor Note: If charting does not take place within 15days, please

reorder.


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• Explain Charting Function Buttons • Navigation Functions buttons

CHART USING STARTED

When Charting PFE orders as started may need be in different increments of time. Example may be books or brochures with many chapter/sections

• Select Disease Process Ed UNSCHED row • Click Started • Order Charting Detail Screen

• Charting Information • Date/time: Defaults to current time • Note Editor: DVT, covered introduction. Include your initial • (DVT = deep vein thrombosis)

• Other Note Editor examples might be: • Specific instructions given to patient regarding dismissal restrictions

Explanation of whom else you may have taught instead of the patient. Example: Patient confused, taught spouse –or- young child, taught parent.

• F12 and Save • Charting Note column: Displays part of note editor • Use of the chart word “started” will be changed to advance documentation to

the permanent record (i.e. PFE Viewer). Nurses are still asked to change the start word to reflect the patient’s level of understanding (e.g. verbalized understanding), as appropriate.

• To continue charting or view complete notes • Select Disease Process Ed UNSCHED row • Click Started • Click in comment field keep original documentation, start new line continue

charting and initial • F12 and Save • Review Worklist Notes and auto trail • Select Disease Process Ed UNSCHED • Click Charting Details button to view note • Select line and show details for auto-trail • Click Back

ADD MORE ITEMS TO PATIENT’S EDUCATION PLAN

Patient needs education on heart failure prevention. You plan to review the brochure with the patient.

• Patient Ed chart tab • Order Entry – Inpatient • E – electronic • Education items available from buttons and/or by searching – same as other

care planning. • Search • Type Heart Failure or MC0389-0


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MC# EDIT ORDER TO VIEW MATERIALS ONLINE

• Select Heart Failure(Heart Fail Self Plan MC0389-04) • MC# indicates it is an education brochure/pamphlet • From the Unissued order section • Select Heart Fail Self Plan MC0389-04 • Click Edit order • On the Order Detail screen, order information section • Select Patient education item • Click Detail, displays printable brochure. • Close Internet Explorer • Click Cancel • Click Issue Order: Order now appears on POC, Order List, and Worklist. • Patient Ed Work list. • Select Heart Failure Row • Click Verb Undst • Chart Heart Failure, by using ecodes • Entering using Ecodes displays in viewer

VIEWER We want to view the completed Patient Education Documentation so far

• Patient Ed • Patient Ed – View • Viewer will show both inpatient and outpatient education • Will not display items In Progress • Patient Ed Worklist Charting section: • Displays items charted against; but not In Progress items (Disease Process

Risk Factors Ed item) • (Mention) Worklist will display all education orders.

Viewer displays completed orders.

UNDO CHARTING Select Row and click Undo Charting. Will undo only the most recent charting.

DISPLAY EDUCATION ORDERS ON POC

• View Education Order from the Plan of Care Screen • Plan of Care screen • Show Orders • Education Orders = XEDUCA orders subcategory • Exit Profile • Home

DISMISSAL AND REMINDER:

Patient is being discharged from the hospital. The software will recognize that a patient status of discharged means that the orders are no longer needed. Therefore, we do not need to DC orders at the time a patient is being discharged from the hospital. Important to review education worklist for uncharted/in process (Ip) items. You need to chart as soon as possible. Orders will disappear about 1 hour after patient is discharged in the system. At that time the orders will disappear from the Worklist and cannot be charted on.


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Instructor Note: Discontinuation of Orders upon Patient Dismissal Due to safety issues related to transfers between hospitals, including Generose and Rehab, the automatic discontinuation of orders on the Plan of Care Order Profile will be one hour. If you have not documented the Patient Education worklist items within an hour after patient dismissal, you may need to reorder the education plan if the orders have been discontinued. • If worklist item is listed as Started, and continued education were needed,

mark as Needs Reinforcement at dismissal; update the editor to reflect the education need.

• If an education order is not needed, navigate to the POC and DC/Cancel order.

• Have student complete charting • Chart V on the Disease Process Education: • Verify Reciept Done Charting term will display as complete • Review Dismissal Summary Instruction, Verbal Understanding • View Patient Ed, Patient Ed – View • (MES FYI: @ symbol remains in Viewer on Disease Process Educ from

original worklist note; even though no comment. Original Worklist note still viewable on Patient Eduction worklist using Review Audit button


SCENARIO • Hand out scenario.

Checklist Updates

Date Concept Update

6-15-2010 Page 1 MES Classroom Order Set

Contact Information

6-15-2010 Page 16 Waiting for new wording in regards to Chart + row in I&O

Margaret Senn to send new info

6-15-2010 Page 24 Advanced Diet as Tolerated

Changed the scenario to edit replace the NPO diet order

Future Change for November

• click Add/Edit Note • Click Started, for

November Time change, Add Edit Note button to be removed.

POC • Updates


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