Clinical Documentation
Section: General – Documenting in SCM – Basics
When to Document on Paper and When to Document Electronically
If your patient is unstable and documenting electronically will compromise patient safety you CAN document on paper until the patient is stable or it is safe for the patient to convert to electronic charting. Cardiac arrests, Level 1 Traumas, Stroke Alerts, and CTAS 1 patients will be documented on paper.
Process for converting from Paper to Electronic
In your progress notes section on paper write see electronic documentation for further charting. Ensure you document the date and time on your note
In your progress note section on your electronic document add a single time column and type see paper charting for previous assessment
Process for converting from Electronic to Paper (Code Blue, Conscious Sedation)
In your progress notes section add a single time column and document refer to paper documentation (specify Code Blue record or Conscious Sedation, if applicable)
Once you are ready to convert back to electronic charting enter a progress note for that time and document Conscious Sedation completed refer to electronic charting for future charting
Opening a New Document Opening a NEW Document:
1. Select your patient and click on the Enter Document icon
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2. The Document Entry Worksheet will open. You can search for the document one of two ways: a. Manual Entry allows you to find your document if you know the name of it i. Type the document name in the search field ii. The document name, ALC in this example, will appear under Document Name – double-click to open the document
b. Start of Browse Menu is a navigation tree that allows you to narrow down your document search without needing to know the exact name of it i. Select Start of Browse located in the drop-down menu on the left hand side of the Document Entry Worksheet.
ii. You will see the following options and will need to select one to further narrow down your document search. These options are expanded by selecting the beside the area you wish to open iii. You will then need to select one of the subitems. Once you do this it will bring up the documents associated with that area and care provider type iv. Select the document you want to open located under Document name and then click on Open
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Creating your Personal Document Preferences
By creating your Personal Document preferences, the documents that you utilize will automatically display when searching for your documents
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To create your Personal Documents:
1. Click on Preferences in the Taskbar and then select Document Entry. The Personal Document Entry window opens
2. Under All Documents, click on the + button in front of the type of department that you work under. This will open a list of roles that can include Nursing, Physician, Interprofessional Practice, and MOA 3. Click on the + button in front of your role. A list of documents appears 4. Click on one of the documents that you will use – it will become highlighted blue 5. Click Add. That document now appears in the Selected box 6. Repeat steps 4 and 5 to add all the documents that you will use
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7. Click Close
Navigating through the Document
The structured note document will open in its entirety so that you can scroll through the entire document to certain sections for data entry
As an alternative, you may use the Navigation Panel to locate specific sections of the document:
Pinning the Navigation Tree
1. At the left side of the document, click on the Sections tab to open the navigation tree
2. Click on the pin to lock the Navigation Panel in place. You may need to make the navigation tree wider by hovering between the navigation tree border and the document border until the widening arrow icon on the mouse appears. Drag the mouse to the right until you can see the navigation tree fully
3. Select the section of the document for data entry
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Navigation Tree (Sections)
The navigation panel on the left side of the screen shows all the major headings in the current structured note
• Note the headings with asterisks (**) and that are in bold
• Sections with asterisks contain information that has come from a different note and will be included as documented by you in your note, so this information needs to be validated by you with the patient before finalizing the note
• Bold items contain the information that has flowed in but has not been saved yet, it is a visual reminder to check the area for the information that needs to be validated
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• Always check the navigation tree before saving to make sure that no new information has flowed in needing validation (Bold and/or new **). For example, if a physician and RN are documenting at the same time, information may flow from one document to another and needs to be checked by the other person before saving. As we know, the bedside nurse often gets a different story from the patient than the Triage nurse, and this story is also often different than what the physician gets
• Documentation in the electronic world is much more fluid than on paper and requires a slightly different workflow
• Prior to electronic documentation you never had to worry about what someone else would add to your document before you started or before it was finished and signed!
• Each section may be accessed directly by clicking on the heading to open the section tree and also the first page in that section, and subsequent pages may be accessed either directly from the tree or by clicking on the navigation arrows to step through each section in order
Preview Tab
The Preview tab will open a preview window allowing you to review your final document before saving it
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How to Change Date of Service
Note: Changing Date of Service can ONLY be done when charting on a NEW document. Once a document is saved, Date of Service cannot be changed.
Open a NEW Document
1. Select your patient and click on the Enter Document icon
2. The Document Entry Worksheet will open. Change Date of Service if different from the defaulted date of today’s date 3. Enter name of document in the search field 4. A list of document(s) matching the search query will appear – double-click to open the document
You can also change the Date of Service within a document at the top of the document as seen below.
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Adding a Cosigner
Physicians
As a “LEARNER”, a CO-SIGNATURE IS REQUIRED for the patient to show up on the Attendings Patient List. As a “LEARNER”, you will be able to save Documents only as “Incomplete”. A checkbox is available on the top of the “Enter Document” icon, check the “Co-signer” box and ensure your supervising physician is listed as the provider. Alternatively, you are able to check the Co-signer box on the left sided “Sections” navigation pane, as below (make sure the Care Provider is your supervising physician)
Other Care Providers Students can enter notes which will be cosigned by their preceptor After opening the electronic document, click on the Document Info Tab (left hand side of document)
Click in the box under Co-Signer(s)
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The Co-Signature window opens > select Other > enter in the preceptor’s name > select Search > select the correct person from the list > select OK
Create the document Click Save. A pop-up message will appear indicating that students will not have the right to save the note as complete
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Click Submit as Incomplete The Reauthentication Window will appear > enter your password In the Documents Tab, the signature status of the note will appear as ‘Signed w/ additional Signatures Pending’
The preceptor will be responsible for modifying the document (if required) and saving the note as complete
It is recommended that preceptors have the To Sign and Incomplete Document columns added to their patient list in order to keep track of student documentation o Select the Visit List Column icon o From the Available Columns list, select desired column o Click Add o You may sort the order of the column by selecting a column and clicking the Move Up or Move Down buttons
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Components of the Document
A. Structured Note Toolbar
Copy Forward Allows you to copy information from a previous note. You can copy forward an entire document or sections of a document from a previous note or visit using the Copy Forward button located at the top of the new document that you have opened. This option will only work for the same observation
Click on the Copy Forward button. The Copy Forward Information from Previous Note window opens
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1. Under Documents – Click on the document you wish to copy 2. Select the sections you want to copy forward to the new note by clicking in the squares in front of each section 3. Select Copy Items Into Current Note 4. Information would require validation and changes made as required
Refer to Note
Allows you to refer to information in another note without reassessing it. Refer to Note will pull the information from another note with a reference attached to it
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Click on the Refer to Note button. The Refer to Note Information From Previous Note window will open
1. Under Documents – Click on the document you wish to copy 2. Select the sections you want to refer to in the new note by clicking in the squares in front of each section 3. Select Reference Items in Note
Preview
The Preview Button will open a preview window allowing you to review your final document before saving it. The preview pane can be displayed on the right side or on the bottom of the
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Structured Notes Entry worksheet depending on which option you select in the Preview drop- down menu
**Please note that using the preview option will slow down responsiveness of documentation during charting**
Modify Template
Opens the Modify Template menu. This menu allows you to modify the template of your document and from here you can add or delete sections of the document
1. In the Structured Notes Entry window, click Modify Template. The Modify Template window opens 2. Select the check boxes next to the sections you want to add. Deselect an item to remove it from the note 3. To save the template, do one of the following: a. To use the template for all the patients on your patient list, select Save Template for Me b. To use the template for the current patient record, select Save Template for Patient
Navigation Buttons
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The First button brings you to the first heading at the very beginning of the navigation tree in the document whereas the Last button will bring you to the last heading in the navigation tree at the very end of the document. The Previous button will bring you to the previous heading in the navigation tree and the Next button will bring you to the next heading in the navigation tree
B. Date and Time Fields Date fields are set-up to display as day-month-year and can be entered 4 different ways (time fields use the 24-hour clock):
Typed manually, by clicking on the dd field, MMM field and then the yyyy field Chosen on a calendar by clicking on the C Entered for previous days, by clicking on the T, typing “T-1” and clicking Enter to enter the date the day before, or typing “T-#” and clicking Enter with # being the number of previous days you are entering Entered for the current date and time by clicking on the
Please Note: The above options allow you to back-date
C. Single Select and Multi-Select Buttons
Round buttons only allow one choice while the square buttons allow one or more choices
When wanting to deselect a single select item, right-click on the item and select Delete Data from the menu that appears:
Multi-select buttons can be unselected
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D. Free Text Fields
Sections of the document may have free text fields, areas of white space, that allow you to type in whatever you want to document
Use acronym expansion to speed up your documentation in the free text fields. Please see the Acronym Expansion section of the manual for a more detailed explanation
Please do not use the following special characters, &, /, ~, ^, when entering information into the free text fields
E. Drop-Down Menus
Drop-down menus allow users to select from predetermined options within a list by selecting the button as seen below
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F. Ellipsis
Three dots (…) called ellipsis after a field name indicates that more data fields are hidden (when this field is selected, more fields related to this question will be revealed right under the selected field)
G. Mandatory Field
The icon indicates that the observation is a Mandatory Field, and the clinical document cannot be saved until charting in this section is completed
Once an item is selected, a pop-up window appears reminding you to select and enter necessary fields in the Patient Designated ALC & Waiting for… section, which is located just above the last section on the note called Discharge Status
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H. Incomplete Icon
The icon indicates that an observation is significant. The clinical document will be saved as Incomplete until an item in this Significant Field is selected. This rule is just a reminder to enter data into this section when necessary. The document saving as incomplete is not an issue
I. Autocalculation
Some documents may contain a section that will autocalculate a measurement or score based on entered in values. In the example below the BMI is autocalculated when the patient’s height and weight are entered in the appropriate sections
J. Add Item Button
Within documents you can perform certain functions by using the Add Item buttons as seen below
This is the Adding New Care Providers button. When you select this button it opens the Care Providers (Adding New) menu. From here you can add care providers. Please see How to
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Add or Update a Care Provider (Physicians) in the manual on adding new care providers.
This is the Adding Significant Events button. When you select this button it opens the Significant Event (Adding New) menu. From here you can add in significant events to a patient’s chart. Please see Entering a Significant Event in this manual for more detailed information on how to add a significant events
This is the Adding Health Issues button. When you select this button it opens Health Issues Manager. From Health Issues Manager you can add in Health Issues to a patient’s record. Please see the Health Issues Manager portion of the manual for more detailed information on Health Issues
This is the Refresh button. This button manually refreshes your screen and it allows you to see the latest data that has been entered on your patient
This is the Restore Original Sort button. Right now it is not currently being used
K. Body Images
Some documents, like the ED Nurse Admission document, allow you to insert body image templates that you can modify to visually depict assessments. The standard defaults for the images are Adult Whole Body Front/Back and Adult Whole Body Side and Pediatric Front and Back
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To modify an image click on the desired template to open the Image Annotation Dialog window that allows you to draw what you want to depict
The pen button allows you to draw on the image
The brush button allows you to draw thicker lines on the image
The eraser button allows you to click on the area of the image that you wish to erase
The undo button will undo the work that you last created
The delete button will delete all of the work that you created
This menu allows you to adjust your pen sizes, pen colours and eraser sizes by selecting what you want from the drop-down menus
When you have completed the drawing in the Image Annotation Dialog window, click OK and it will now be viewable in your document
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Image Comments
You can free text any comments that you want to make regarding your image in the Image Comments section under the image. See the example below
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Modifying Body Image Templates
To add or delete body image templates Click on Modify Template
The Modify Template menu will open. This menu allows you to modify the template of your document, and from here you can add or delete the images by scrolling down to the Body Images section or by typing body images in the search window
Once you are in the body images section you can click on a check mark to remove a selected image type or click in an empty box to add an image type. In the example below PEDIATRIC is deselected and Eye is selected
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This is what the body images in the document will now look like with the template changes
Acronym Expansion
Acronym Expansion is a shortcut tool in SCM that allows users to enter in an acronym that is then expanded out into words and/or sentences. In order to utilize this function the acronyms
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must first be created within SCM and mapped to specific words or sentences. It is used for commonly entered in phrases and words
Creating New Acronyms
When creating a new acronymn note that the acronyms are case senstive. If you set up an acronym that is capitalized you have to type it in everytime with the capitalization for it to work. If you do not, the acronym will not expand.
On the toolbar choose Preferences and Acronym Expansion
When the Acronym Expansion Maintenance Dialog box opens, choose Add
When the Acronym Expansion-Add\Edit\View\Dialog menu opens, type in the acronym you wish to use under the Acronym box with a period in front of it. Note that when adding an acronym, in the Acronym box, enter the acronym but do not use the following characters
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except as the first character “.” (period), “?” (question mark), “:”(colon), “;” (semicolon), “,” (comma) and “!” (exclamation mark). The aforementioned characters are called acronym terminators, which are reserved characters you enter to open the acronym search pop-up window. For example, .wbc is an example of a valid acronym whereas w.b.c. is not
Next, enter in the text you wish to see in the Expanded Text area. When you are done select OK, or Apply if you want to add more than one acronym. The maximum amount of characters is 20,000. However, application performance might degrade if you use lengthy expanded text.
In any free text area on a structured note or flowsheet, type in the acronym. Remember to use the period at the beginning of your acronym that you wish to expand
Press Enter or the space bar and the Expanded Text will appear
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Importing Acronyms from other users
You can also import acronyms from other users instead of creating your own acronyms.
On the toolbar, choose Preferences and Acronym Expansion…
When the Acronym Expansion Maintenance Dialog box opens, choose Import From Other User.
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The Import Dialog menu will open. Go to the drop-down list Select From Existing list to select a care provider’s premade acronym list. The list is organized alphabetically by care provider’s name. Click on a care provider that you wish to borrow acronyms from. Once selected, that care provider’s acronyms will be displayed and you can select the acronyms you wish to borrow by clicking in the empty box next to the acronyms that you want. In the example below, .behl and .ecg are selected. Once the acronyms are selected click OK
Editing Imported Acronyms from other users
Once you have imported Acronyms from other users you have the ability to edit the expanded text portion of the created acronym. You cannot edit the acronym created by the user
Select the acronym you wish to edit, .ecg in the example below, and click on Edit
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Overwrite the current expanded text with what you wish to see. In this example, “ECG technician in to perform 12 lead heart tracing” replaces “ECG complete”. Click the OK button when you are satisfied
Renewing the Length of Time for Data Entry
When you open a document for charting, you are “locking” that document for data entry by yourself - another user has read-only access to the document until you save the document
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After 10 minutes of data entry or inactivity in an electronic document, you will receive a pop-up message asking you to renew your time in the document for another 15 minutes
When you do not renew your time on the document, you risk another user opening the document, charting and saving the document without you saving your data entry. You will not be able to save your charting
You will need to copy and paste your free text information into a Word document, exit the document, re-open the document to copy your information into the document and complete your data entry
How to Save your Document as Incomplete
To save the document as incomplete, you can either:
1. Select Incomplete at the bottom of the document
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Or…
2. Click Save and the following pop-up message will appear. Click on Submit as Incomplete
How to Save your Document as Complete
To save the document as complete, please remember to complete the note - select yes
A Reauthentication Window will appear – enter your password
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Editing a Document
On the Documents Tab, highlight the document you want to Edit, right-click and choose Modify Document. This will open the document and you can make the necessary changes
After saving the Document you edited, you will see the icon that shows the document has been revised
Appending a Document
**Purpose: To add information to chart once note has been completed and patient has left department.**
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If patient is no longer in the department, you may have to search for the patient. (See instructions below)
1. Go to Documents tab 2. Click once on the note you want to add/change information on 3. Click on the Append icon in the tab toolbar or right-click and choose “Append Document”
4. A note similar to this will appear and you can enter and save your information
5. Addendum Note will appear on summary of structured note with date and time entered
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Viewing Corrections
Open the document and then click on the Corrections tab. The document will display all items that have been changed in RED. A red C will appear after information that has been added to the document where none existed before the last save
Cancelling a Document
If you have entered a document in error, i.e. on the wrong patient, you may need to cancel it. Highlight the document, right-click on the document and choose Cancel Document
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You will be asked for a reason and in the drop-down “Entered on Wrong Patient” can be chosen. Other reasons may be entered as free text
Note that once the document has been cancelled you will see the icon that shows the document has been cancelled
Viewing Document Status
Highlight the document, right-click and choose View Status History
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The Status History shows Who modified the document, the Status at that time, and the Revision Status
Health Issues Manager
The Health Issues Manager is a module in SCM designed to maintain an up-to-date list of current and active Health Issues for the patient. The Health Issues list serves as a centralized problem list for clinicians to document and reference a list of diagnoses or conditions that the patient currently has or has experienced
Accessing Health Issue Manager
You can access Health Issues Manager one of three ways:
1. Clicking on the Health Issues icon in the main toolbar
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2. Clicking on Health Issues found under the Data Entry section of the Patient Info tab
3. Clicking on the red caduceus icon within a document
Entering a Health Issue
When the Health Issues Manager opens, you will need to search and select the Health Issue that you wish to add to your patient’s Medical History
Adding Medical Hx, Admitting Dx, Discharge Dx, Secondary Dx
1. Go to the Add New Health Issue section of the Health Issues manager at the bottom of the Health Issues Manager page
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2. Select the type of Health Issue you wish to add (e.g. Medical Hx) under Select a Type
3. Select the Full Catalog Search tab: a. Type the name of the health condition in the free text box b. A drop-down box will open under what was typed. From this drop-down you can select a more specific Health Issue, if it applies, but it is not necessary
c. Click the search button
d. Highlight the correct Health Issue and click on the Add Details button if a
Description needs to be entered, or simply click on the Add button e. The chosen Health Issue will then be added under the Health Issues tab in the window above Add New Health Issue f. Click the Close button once you are done adding in Health Issues
Adding Surgical History
The Surgical History is free text only. You cannot do a search for the specific surgery
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1. Go to the Add New Health Issue section of the Health Issues Manager at the bottom of the Health Issues Manager page
2. Select Surgical Hx under Select a Type
3. Once selected, the Health Issue Details menu opens where the Surgical History item can be free texted in the mandatory free-text field denoted with the next to Health Issue
4. The date can be entered by first selecting the M/Y selection box and typing in the first three letters of the month followed by the four numbers for the year (e.g. Aug 1992). If the date is within a reasonable window, you can also select the Calendar Icon and use up and down arrows to choose your date
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5. Once the surgical history and date have been entered, select Save Changes and the window will automatically close. If you choose to enter another surgical history item, then select Apply
6. You will be taken to the Health Issues Manager window where you can see the added surgical history. Select Close when you’ve finished reviewing
Adding Details to your Health Issue
You can add in more detailed information, such as the onset date, of the selected Health Issue by clicking the Add details button next to your searched for health issue in the Add New Health Issue section of Health Issue Manager
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Once the Add details button is selected, the Health Issue Details menu will open. Within this menu, you can free text in a more detailed description of the Health Issue
You can also enter in the Onset Date of the Health Issue by first selecting the M/Y selection box and typing in the first three letters of the month followed by the four numbers for the year (e.g. Aug 1992). If the date is within a reasonable window, you can also select the Calendar Icon and use up and down arrows to choose your specific date
Adding a Health Issue to Favorites
Follow steps 1-3c from the Entering a Health Issue section of the manual. Select the Health Issue you would like to add and click on Add to Favorites on the right hand screen of the Add New Health Issue section
The Favorite Health Issues menu will open. From the Favorite Health Issues menu you can create a category for the Health Issue to be organized in or you can select OK and the Health Issue will be saved under the
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Creating Categories for Health Issues Favorites: Creating categories for your favourite health issues enables you to organize the health issues allowing you to find them easier when you search for them
Once you have selected the health issue and clicked on Add to Favorites the Favorite Health Issues menu will open. From this menu, click on Create Category
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A folder labeled New Category (highlighted in blue) will appear under My Favorites. Type in the name you want to call your New Category folder. When completed, click on OK
Within the Add New Health Issue section of Health Issue Manager under the Favorites tab, the newly created category and Health Issue will populate
Importing another Clinician’s Favorite Health Issues
1. Click on Health Issues… under the Preferences drop-down menu in SCM Viewer window
2. In the Health Issues Option window, click on Copy From…
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3. Type in the Clinician’s name that you are copying from 4. Highlight the correct Clinician under Name 5. Click OK button
6. Click on Copy All, or highlight the favourite Health Issues you would like to copy from the selected Clinician under Favorites for e.g. Behl, Vern and click on Copy Selected. The chosen favourites will appear under My Favorites
7. Click OK button
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Adding a Health Issue from Favorites
1. From the Health Issues Manager window, select the Favorites tab. You will now see all of your listed favourites 2. Select the Add button next to the Health Issue you wish to add to your patient
3. It will then add the favourite health issue to the Medical History List
Discontinuing a Health Issue
If a patient has a listed Health Issue that is no longer applicable (i.e. their hypertension has now resolved), you can discontinue this Health Issue:
In the Patient Tab, ensure you are in the Health Issues Summary View
1. Locate the health issue you wish to discontinue and double-click. This will open the Health Issue Manager
2. Select Discontinue on the top left-hand corner of Health Issues Manager and the health issue you have chosen will drop-off your Medical History list
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3. To see all discontinued or deleted Health Issues, select Clear All Filters
4. You should now see the struckthrough Health Issue (as seen below):
Reinstating a Health Issue
If a discontinued Health Issue needs to be reinstated (i.e. a once normalized hypertension has returned), we can Re-activate this by:
1. Opening the Health Issues Manager; ensuring all filters are cleared by selecting the Clear All Filters icon
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2. Select the struckthrough health issue and select Re-activate
3. You will see an H next to the re-activated health issue, and if double-clicked, it will open the Modification History window and show the changes made, by whom and when, to the Health Issue
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Deleting Incorrectly Entered Health Issues
*** The only time a Health Issue will be deleted, is when it has been entered in ERROR
1. In the Health Issues Manager window, highlight the incorrectly added (duplicate) health issue. Select the Delete button at the top of the header
2. The now deleted Health Issue will appear struckthrough (when filter is off) and will by default have a message saying “Cancelled/Entered in Error…”
3. You will see an H next to the reactivated Health issue, and if double-clicked, it will open the Modification History window and show the changes made, by whom and when, to the Health Issue
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Significant Events
Significant Events are any events that could affect a patient’s treatment or recovery such as frequent prescription requests, being potentially violent, language barriers, fall risks, etc.
Entering a Significant Event
1. In the Patient Info tab, locate the Data entry section and select Significant Event – this will open the Significant Event (Adding New) window
2. Select Type of event from the drop-down menu
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3. After Type is chosen, the user will then select the Event. Each Type has different Events
4. Enter the Date using either the M/Y section or the Full Date drop-down menu. You may enter in comments in the free text Description section
l
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5. If another Signficant Event is to be entered, select Apply and repeat steps 1-4. However, if finished entering in Significant Events, select OK
Flowsheet Charting
The flowsheets in SCM are for documenting clinical assessments, interventions, vital signs, and fluid balances. Currently, they are only used by Emergency Department staff. The four flowsheets are:
1. ED Assessment and Care 2. ED Triage Reassessment 3. ED Vital Signs 4. Intake and Output
Adding Time Columns
In order to document in the Flowsheets you need to add a time column. The time column can be added in one of two ways:
1. Select the Add Time Column Options in the tab toolbar
2. Right-click anywhere on the flowsheet and select either Add Multiple Time Columns or Add Single Time Column
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Time columns can be generated from the time of registration of this visit and up to one hour into the future
Adding Text Label to Time Column
The time columns of flowsheets can be labelled. Columns may be labelled to tie the observations to medical interventions, like the administration of IV narcotics. To perform this function, right-click in the top of column after a new time column has been created and select Edit Text
Enter the intervention into the free text box. The data entered will appear at the top of the column under the date and time
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Documenting in Flowsheets
Once a time column has been generated, you can document in the fields. The fields of the flowsheet are in rows with a row heading. Each row will open by left-clicking your mouse in the blue row. This works for the flowsheets beginning with ‘ED.’
Adding Parameters
The treatments and observations that are not frequently utilized are housed within the ‘Add a Parameter’ function. This functionality keeps the flowsheets manageable by having large amounts of infrequently used observations and interventions in the background. To open it, right-click on the flowsheet and select Add Parameter
This will open the menu for the user to find the parameter they wish to add
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ED Assessment and Care
The ED Assessment and Care (EDAC) flowsheet is used for documenting the systems assessments of the patient and any interventions that are carried out. It is an expansive flowsheet that has the ability to document most all observations of the physical assessment and interventions performed
The Assessment sections of EDAC begin with a Within Normal Limits (WNL) statement. This follows the process of charting by exception. If the WNL statement is not fully in context, the documentor can hover over the blue arrow on the left side of the cell. This will open the statement making it easier to read
To document in the section, read the WNL statement. If the statement applies, click next to it in the newly created time column. The assessment window will open. Choose the single-select radio button by WNL, then OK and then move onto the next cell
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If the WNL statement does not apply, click next to it in the newly created time column. Choose WNL except, and in the next cell identify which observations are variances from the WNL statement. Avoid double charting by moving to the next cell, if the WNL statement applies
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ED Triage Reassessment and ED Vital Signs
These two flowsheets are similar in their design and use. The ED Triage Reassessment is only utilized when the patient is in the Emergency Department waiting rooms. Values are entered in the appropriate fields after creating a new time column. After a value is entered, the flowsheet will take you to the next cell to gain more information about the observation. If you do not have information to document in a field, go to the next area that you need to document in
How to find Progress Notes Section
Note: To find the nursing progress notes, open the Vital Signs Flowsheet, go to Nursing Information section and you will find Progress Notes. Add a single time column and free text your progress note
Intake and Output Flowsheet
The Intake and Output flowsheet (IOFS) is used to track cumulative totals during care. This flowsheet also has Add Parameter content so that multiple observations can be specified and tracked. The flowsheet has observations that are premade and present on all flowsheets
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Data entry occurs after the addition of a time column. The IOFS maintains cumulative totals for both the shift and daily volumes. Every entry onto the IOFS Flowsheet will update the totals automatically.
Labeling IV lines Within an Intake and Output Flowsheet
1. Right-click on fluid you are wanting to label with a specific line 2. Click Modify Row Label
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3. The Modify Parameter menu will show up. Fill in the corresponding boxes (e.g. #18 R forearm under “Site”)
4. Your row is now labeled **Each Intravenous Fluid row represents a different IV site running that fluid, not additional bags initiated on the same line**
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Hanging a New Bag on an IV line
1. Right-click on specific time column when you are hanging your bag, click on Enter Bag Details
2. Type in bag number and total volume in that bag and click OK
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3. Your row now has Bag Details
Documenting Intake
Document the intake on the appropriate row (e.g. Sodium Chloride 0.9%) by clicking in the newly created time column and typing in the amount that has been absorbed
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Documenting Output
Document the output on the appropriate row (e.g. Catheter, Indwelling Urethral) by clicking in the newly created time column and enter the appropriate volume of output
Documenting IV Rate Change
1. Right-click on the specific IV type that you want to change the rate of
2. Select Modify Row Label
3. Change the IV rate to what you need it to be under Rate
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4. You can see the rate change history by right-clicking on the specific time column and IV type that you changed the rate of and selecting Show History
5. You will see rate changes as highlighted in the red box
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How to Discontinue Running Fluid on an IV Line
1. Right-click on the specified fluid to be discontinued 2. Click Discontinue
3. You will see the row heading is greyed out and new time boxes will also be greyed out
IV Insertion
1. Click on Flowsheet tab and select ED Assessment and Care
2. Select Access Devices, then select Peripheral IV # 1 if it is your first IV to be documented. If there are more than two peripheral devices, you will need to add the additional IV lines to document on using the Add Parameter function
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3. If procedure done by physician, document ‘Inserted by Dr.(name)’ in the free text box
4. Label the IV by right-clicking on Modify Row Label
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5. Document the IV on the Intake and Output for fluid administration
Letters Icon
The Letters Icon allows you to create and save patient letters and referrals
Adding the Letters Icon to the Main Toolbar
If you do not have the icon on your main toolbar, you will need to add it. Follow the steps below
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1. Click on Preferences, then select Toolbar… to open the Customize Toolbar menu
2. To add the Letters button, select the item from Available Buttons and click the button
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3. This will move the button into the Selected Layout. Click on OK
4. Your main toolbar will look similar to this with the Letters icon now added
Using the Letters Icon
To access, create and save/print the patient letters (handouts) and referrals, you will:
1. Select your patient
2. Click on the Letters icon
3. Select your template from the drop-down list for Choose Template Category 4. Select the letter, referral or discharge instructions from the drop-down list for Choose Letter Template
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5. The patient’s name, date and medical records number (MRN) is autopopulated. Information will need to be entered on the letter or referral anywhere you see [enter name], [enter X here], [enter number], [enter Pathway Dates here], [enter reason for referral], etc.
This application functions similar to a Word document - you will highlight the selection with your mouse and begin to enter in the data. If you do not want the information bolded, you can choose to deselect this option. Other options (i.e. italic, underline, etc.) are also available
6. When the data entry is complete, please recheck the information! You can edit information after you save and/or print but before you exit from the application. You cannot modify the letter or referral once it is saved on the Documents Tab – it does not function like other documents 7. Click Save. The Letter Name will be highlighted blue with the patient’s name and date autopopulated
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8. Change the name to the actual name of the letter or referral. Click OK
9. Click Print. Your printer will default. Click OK
10. When completing multiple letters or referrals, select the next letter or referral from the drop-down list for Choose Letter Template and proceed with steps 4-9 11. If you are done saving and printing your letter(s) and/or referral(s), click Exit
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12. The letters or referrals are saved under the Documents Tab. Click on the Display View icon and select Letters. The letters will display in the field below. Double-click to open the letter or referral
Status Board
The Status Board is a visual communication tool utilized by all disciplines illustrating the real time status of patients on a clinical unit. Health care providers (HCP) can view current and past information on patients regarding care providers, previous hospitalizations, dictated, electronic and scanned documentation, regional lab and radiology results, current orders, planned discharge date and much more
Changing Status Board Views
“Department” – drop-down list according to which hospital and department you are working in (e.g. RUH 6000, SPH 7M, SCH Emergency Department). You will only be able to open the status boards that you have the security rights to. “View” – drop-down list that is sorted to the particular area you are working in e.g. ERC, Active, Trauma, Children’s Area, etc.
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Common Status Board Columns
Columns Functionality Location Current location of the patient STS (Bed) Readiness status of the unoccupied bed
Status updates to dirty when patient is discharged STS Drop-down list of options: (Patient) Admitted (ADM) Pending Discharge (PD) Pending Transfer (TX) Consult Pending (C2C) Discharged (DC) ADM - default status when the patient is registered PD – when selected, the cell will flash green TX – when selected, the BC4 Timer starts. Use for transfers to Pediatrics C2C– when Consult Service is selected, the status will change to C2C DC – when selected, the Remove Patient window will appear. Select Yes to remove the patient to the Inactive Patients View. The patient will be discharged by the Patient Placement Clerks in the Acute Care Access Services (ACAS) Department Patient Patient name with color-coded background for genders (i.e. blue – male, pink- female)
When the patient has a confidential status, the cell will be blank with the confidential person icon:
Confidential Status will also appear in the blue Patient Header:
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Age Pediatric patients will have age denoted in years and months up to age 10 Isolation Drop-down list of options that match the colour-coding system for the Alert SHA Isolation Alerts
When an isolation alert is selected, the isolation icon will display in the patient name column
Consult Drop-down list of options for specialty physician consultations Service & When selected, the Consult Timer will start and the STS Column will Consult update to C2C Timer When the consultation service arrives to the clinical unit, change the Consult Service to a blank field and update the STS Column to ADM. This will stop the Consult Timer New Result New Result flag will autopopulate as results become available from Laboratory Services, Medical Imaging, and Non-Invasive Cardiology Red – abnormal results Green – normal results Yellow - text document
Double click on the flag to view the results. Select Don’t Clear Flag or red X (top right corner) to close the window BC4 When arrangements have been made by the physician to transfer the Assigned &
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BC4 Timer patient, the STS Column will need to be updated to Pending Transfer
This update to the patient’s status will start the BC4 Timer When a bed assignment has been entered in Patient Flow, the bed assignment will display in the BC4 Assigned Column with the bed number and the readiness of the bed: Brown – dirty Grey – occupied Yellow – process in cleaning Flashing green – clean
Comments Free text
Examples for using this column are: Specifying a second consult service Transportation arrangements Special tests (e.g. lung tap)
Entering in Data
There are several different ways that patient data can be entered on the status board:
Drop-Down Lists
Drop-down lists allow for a single selection to be chosen. To select the blank field or option for the cell in a column, open the the drop-down list and select the blank field
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Free Text Cells
Select the patient. Single click in the cell to enter data
Checkbox Cell
Select the patient. Click in the box to add a checkmark. In the example below, one of the patients is being cardiac monitored as indicated by the checkmark
Icons in the Patient Name Column
indicates that the patient is on some type of isolation precaution
indicates that the patient has requested that they be treated as a “Confidential Person” – which is entered in Sunrise Enterprise Registration. The patient name will display as a white cell, but you can select the patient and their information will still be displayed in the header. All other information will display as usual
indicates a patient 70 years of age or more. This is a ‘heads up’ to all health care workers to provide urgent intervention and services to patients that may assist in preventing hospital admissions in the emergency department. Furthermore, on clinical units this icon identifies patients that may need more services on discharge
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Locking Columns You can lock selected columns so they remain visible when you scroll horizontally. To lock columns, right-click the last column to keep locked and choose Lock Column
The shaded columns indicate the locked columns
Unlocking Columns To unlock columns, right-click a specific column and choose Unlock Columns
Show History
To show the history on any cell, click on the cell > right-click and select Show History
This will show a record of all changes made to the cell and by whom
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Removing a Patient from the Status Board
**Prior to removing a patient from the status board, please check with your educator as to who is performing this work**
Select the patient you wish to remove and right-click on the mouse. A list of options will appear
Select Remove Patient. Patient will be removed to the Inactive Patients list
Returning a Patient to the All Beds View
If a patient has been removed from the All Beds View in error, go to View above the status board
Open the drop-down list and select Inactive Patients
Select the patient you want to return to the All Beds View. Right-click and select Return Patient
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A Return Patient menu opens asking you what location that you want to return the patient to. Click the down arrow for a list of locations. Select the location. Click OK
Discharging Patient from Status Board (Emergency Department Only)
This step is completed when a patient has left the emergency department. However, only applies to ED visits and not ED inpatient visits
1. Patient is removed from the Status Board by the Emergency Department RN and is now on the Inactive Patients list 2. Find patient on Inactive Patients list, right-click on patient and select Discharge Patient
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3. From the Visit Discharge window, click on the drop-down arrow for Actual Date and click on the date the patient was discharged 4. Click in the Actual Time textbox and type in the time of discharge 5. Click on the drop-down arrow for Disposition and select the disposition 6. Click on the drop-down arrow for Discharge Location and select the location the patient was discharged to 7. If additional notes need to be added about the discharge, click in the Notes text box and type in the additional information 8. Click on the Discharge command button *Please note that items 3-6 are mandatory fields*
ED Visits – ED staff to complete discharge ED Inpatient visits – ACAS PPC’s to complete discharge
For patients that expire in the ED: Time of Death to be used as discharge time ED visit expirations – follow ED visit discharge process ED Inpatient visit expirations – ACAS PPC’s to complete discharge
**Patients will remain on the Inactive Patients list for up to four (4) hours once the visit is discharged, or indefinitely if the discharge process is not completed**
How to Revert an Accidentally Discharged ED Visit
Make sure you have the patient in context. If not, you need to perform a patient search to find the patient
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Select the correct visit from the Show Visits menu. The correct visit will have a Visit Status of DSC Double-check that you have the right patient in context. The patient will have a DSC date in the patient header
1. Select Patient Info Tab 2. Under the Data Entry section click on Discharge 3. A Visit Discharge menu will open. Make sure information is correct and select Cancel Discharge 4. The Location Menu will open. Under the New Location section, check that it is set to the
bed the patient was previously in. You can click on to assign a different bed if needed. Click OK. The patient header will no longer have a DSC date
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Section: Flowsheet Documenting A to Z
Airway Assessment of Drooling
1. Click on Flowsheets tab and select ED Assessment and Care 2. Expand EENT 3. Throat Assessment-Drooling 4. Add comments for specific airway concerns
Arterial Blood Pressure and Arterial Line
1. Click on Flowsheets tab and select ED Vital Signs 2. Right-click on row header, click on Add Parameter
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3. Select Blood Pressure then Select Arterial Blood Pressure, click Add then OK
4. Document arterial blood pressures here
5. Click on Flowsheets tab and select ED Assessment and Care 6. Right-click on row header, click on Add Parameter
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7. Select Access Device, then select Arterial Line, click Add then OK
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8. Document ‘Inserted by Dr.(name)’ in the free text box, as well as any patient/family teaching done
9. Document Waveform and Site Care in these areas
Cast Application and Ongoing Cast Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Expand Musculoskeletal
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3. If procedure done by physician, document ‘Done by Dr.(name)’ in the free text box, and document patient/family teaching done
Central Line Insertion and Ongoing Care Documentation
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Access Devices, then Central Line, click Add and OK
4. If procedure done by physician, document ‘Inserted by Dr.(name)’ in the free text box. Also document any problems encountered in the insertion as well as patient/family teaching done in the free text box
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5. Row label may be modified if more than one Central Line present 6. Remember to document infusions on the Intake and Output flowsheet
Chest Pain Assessment
1. Click on Flowsheets tab and select ED Assessment and Care, expand Cardiovascular
2. Remember to Add Parameter for cardiac monitoring/ECG rhythm, as well as any heart sounds heard on assessment
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3. Other cardiovascular assessment (e.g. edema) is done under Assessment and Care/Vascular
4. Completion of 12 lead ECG and collection of lab work need to be documented on the Progress Note (Vital Signs/Nursing Information/Progress Note)
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Chest Tube Insertion and Ongoing Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Respiratory, then select Chest Tube, click Add and OK
4. If procedure done by physician, document ‘Inserted by Dr.(name)’ in the free text box. Also place your comments as to how the patient tolerated the procedure here
5. Row label may be modified to reflect location if more than one chest tube present
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6. Remember to add the Chest Tube to Intake and Output and record drainage, and label the row with chest tube location as noted in Chest Tube observation
Colostomy Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Gastrointestinal, then select Colostomy, click Add and OK
4. Document ongoing Colostomy Care here
5. Go to Intake and Output flowsheet to document drainage: Right-click and select Add Parameter - select GI then Colostomy
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Continuous Bladder Irrigation (CBI)
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
3. Select Genitourinary, then select Bladder Irrigation, click Add and OK
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4. If procedure done by physician, document ‘Inserted by Dr.(name)’ in the free text box. Also include any information regarding problems encountered, and patient teaching
Do not forget to add an Indwelling Catheter of the appropriate size and type
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5. Enter Irrigation on Intake and Output: Go to Intake and Output and Add Parameter under Intake - Net
6. Any problems with Bladder Irrigation, or if catheter occludes with clots and needs manual irrigation, document here
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Distal Extremities Assessment and Capillary Refill
Click on Flowsheets tab and select ED Assessment and Care, expand Vascular assessment, add time column to chart
Endotracheal Tube 1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Respiratory and expand to see subcategory
4. Select Artificial Airway 5. In time column, under Type, click and select endotracheal tube and click OK
6. Document ‘Inserted by Dr.(name)’ in the free text box. Also document what was done with ET tube (e.g. attached to ventilator, ventilator settings, bag valve mask, etc.)
7. Re-label the specific airway type to ET tube: Right-click on Artificial Airway row/Modify Row Label: Label artificial airway as ET tube
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Enema
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Gastrointestinal, then select Enema, click Add and OK
4. Document Enema as outlined:
5. Document patient response to enema. If patient having pain post-enema, will need to go to Pain assessment to document pain assessment there
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HDC (Hypodermoclysis – Subcutaneous Infusion) Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
3. Select Access Device, then Subcutaneous Infusion, click Add and OK
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4. If procedure done by physician, document ‘Inserted by Dr.(name)’ in the free text box
5. Remember to document infusions on the Intake and Output
Hemovac Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Skin, then Drainage Tube, click Add and OK
4. In time column, click “Type” and select Hemovac
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5. Remember to add Hemovac to Intake and Output
Ileostomy Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Gastrointestinal, then select Ileostomy, click Add and OK
4. Remember to add to Intake and Output
Incentive Spirometer
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Respiratory and expand to see subcategory
4. Select Incentive Spirometer, click Add and OK
Incision Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Skin and expand to see subcategory
4. Select Incision #1, click Add and OK
Indwelling Catheter Insertion and Care
1. Click on Flowsheets tab and select ED Assessment and Care, then select Genitourinary. Document your assessment and care
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2. If procedure done by physician, document ‘Inserted by Dr.(name)’ in the free text box, as well as any issues encountered, and patient teaching
3. Ongoing assessment and care is documented in intervention area
Intermittent Catheter Documentation
1. Click on Flowsheets tab and select Genitourinary 2. Under GU Assessment, select Void Route, then choose appropriate route
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3. Do not forget to document if you sent a specimen or if you need to record an Intake and Output volume
Infusion – Documenting a Heparin Infusion
1. Click on Flowsheets tab and select Intake and Output 2. Right-click on row header, click on Add Parameter/Drips/Heparin
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3. Document bag info and rates in time box as per other IV infusions
Ensure you document repeat PTT in row label, and document dose, PTT result, and stop/re- start times
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Right-click on observation area and click “Modify Row Label”, enter required information into “Comments:” box
*ENSURE you document the actual dose of heparin on MAR!*
Intake and Output Flowsheet
Jackson-Pratt (JP) Drain Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
3. Select Skin, then Drainage Tube, click Add and OK
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4. In time column, click Type and select Jackson-Pratt
5. Make sure to document the Jackson-Pratt volumes on the Intake and Output sheet
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JVD (Jugular Venous Distention) Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
3. Select Cardiovascular, then Jugular Venous Distention, click Add and OK
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Memory Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
3. Select Neuro, then Neuro Deficit, click Add and OK
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Mobility and Ambulation Assessment
1. Click on Flowsheets tab and select Vital Signs 2. Select Continuing Care, then Activity. This is where you will document the on-going mobility assessment
3. In ED Nursing Admission, you can also complete the Fall Risk/TLR Screening if not completed on the initial documentation
Mucous Fistula Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Gastrointestinal, then Mucous Fistula, click Add and OK
4. Add any additional comments in the Interventions box
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Nasal Trumpet
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
3. Select Respiratory and expand to see subcategory
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4. Select Artificial Airway 5. In time column, under Type, click and select Nasal Trumpet and click OK
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6. If procedure done by physician, document ‘Inserted by Dr.(name)’ in the free text box. Document how patient tolerated procedure, problems encountered, patient teaching, etc.
Nasogastric/Orogastric Tubes
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Paramete
3. Select Gastrointestinal, then select Nasogastric/Orogastric tube, click Add and OK
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4. If procedure done by physician, document ‘Inserted by Dr.(name)’ in the free text box. Also, make sure you chart how the insertion was tolerated, problems encountered, and patient/family teaching
5. Add time column for ongoing assessment of Nasogastric or Orogastric tube
Nasogastric/Orogastric Tube Fluid Replacement Documentation
1. Click on Flowsheets tab and select Intake and Output 2. Right-click on row header, click on Add Parameter/Crystalloid/(ordered fluid type)
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3. Label row with reason for fluid line
4. Leave bag active until done with replacements
Nasopharyngeal Tube
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Respiratory and expand to see subcategory
4. Select Artificial Airway 5. In time column, under Type, click and select nasopharyngeal airway and click OK
6. If procedure done by physician, document ‘Inserted by Dr.(name)’ in the free text box, as well as how procedure was tolerated, any problems encountered, and patient/family teaching
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Nasotracheal Tube
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
3. Select Respiratory and expand to see subcategory
4. Select Artificial Airway
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5. In time column, under Type, click and select nasotracheal tube and click OK
6. If procedure done by physician, document ‘Inserted by Dr.(name)’ in the free text box
Nebulizer Administration Documentation
1. ED Vital Signs flowsheet, Respiratory
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2. Go to Oxygen Therapy section – enter in Flow and in comments section under Delivery Method, type ‘Nebulizer’ if patient uses nebulizer pipe, otherwise use Delivery Method type mask, aerosol 3. Be sure to chart the medication given in the MAR
Nephrostomy Tube Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
3. Select Genitourinary then select Nephrostomy, click Add and OK
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4. Remember to label the row with location of tube (right or left)
5. Add second Nephrostomy tube if needed, and label row 6. Remember to add Nephrostomy tube to Intake and Output, and label the rows in the Intake and Output record
Oropharyngeal Tube
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Respiratory and expand to see subcategory
4. Select Artificial Airway
5. In time column, under Type, click and select oropharyngeal airway and click OK
6. If procedure done by physician, document ‘Inserted by Dr.(name)’ in the free text box, as well as how patient is tolerating the airway, any issues, and patient/family teaching
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Penrose Drain Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
3. Select Skin, then Drainage Tube #1, click Add and OK
4. In time column, click Type and select penrose
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5. Document the Location and any other information about the drain site 6. Remember to add the drain to the Intake and Output and label the drains in the Intake and Output
Peripheral Pulses Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Vascular, then select appropriate pulses (e.g. radial pulses), click Add and OK. For central pulses, select appropriate location (i.e. carotid, brachial), and document the central pulses (as we do with pediatric patients)
PICC Line Insertion and Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Access Device, then PICC #1, click Add and OK
4. Document ‘Inserted by Dr.(name)’ or ‘Inserted in radiology at (time). In the free text box, how the patient tolerated procedure, patient teaching, and on-going assessment and care for the line/site will also be documented in this area
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5. Go to Intake and Output and enter PICC. Label the row as done for IVs, chest tubes, etc.
Rash
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Skin, then Rash, click Add and OK
4. Should be enough detail to document here. Note the drop-down menu choices for additional documentation. There is a free text box for additional information, if needed
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Scrotum/Penis Injury
1. Click on Flowsheets tab, select ED Assessment and Care and then select Pain Assessment. Document Pain Assessment. Note the drop-down menu choices for additional documentation
2. Right-click on row header, click on Add Parameter 3. Select Skin, then Bruising, click Add and OK
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4. Should be enough detail to document here. Note the drop-down menu choices for additional documentation. There is a free text box for additional information, if needed
Stroke Screening Assessment (FAST)
1. At Triage: a. On left navigation panel, expand Screening/Treatment/Protocols and select STROKE SCREEN
b. When entering information on last seen normal, month must be typed out (i.e. Aug), or use calendar accessed by clicking “C” button on date/time box
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2. Stroke Screen is also done under Assessment and Care/Neurology/Stroke Assessment (FAST) or in EDNA under Screenings/Stroke. This would be done with patients that developed stroke signs and symptoms after Triage completed
Subcutaneous Emphysema
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Respiratory and expand to see subcategory
4. Select Subcutaneous Emphysema, click Add and OK 5. Document areas of Subcutaneous Emphysema, comments section for additional documentation
Suprapubic Catheter
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Genitourinary, then select Suprapubic, click Add and OK
4. Document the size, physician who inserted it, patient response, patient/family teaching. There is a comments section to document additional information
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5. Remember to document the Suprapubic catheter in the Intake and Output. Label the row with Suprapubic Catheter
Swallowing Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Neuro, then Swallow Screen, click Add and OK
4. If procedure done by SLP, document ‘done by SLP’ in the free text box and add ‘see SLP swallowing results’
Tracheostomy
1. Click on Flowsheets tab and select ED Assessment and Care
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2. Right-click on row header, click on Add Parameter
3. Select Respiratory and expand to see subcategory
4. Select Tracheostomy, click Add and OK
5. Document ‘Inserted by Dr.(name)’ in the free text box – comments (if done in ER)
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6. Document information in appropriate sections. Comments should also include information on patient teaching to family/patient
Traction, Splint and Cast Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
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3. Select Musculoskeletal, then Traction, click Add and OK
4. If procedure done by physician, document ‘Done by Dr.(name)’ in the free text box
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***Remember that Conscious Sedation will be documented on paper – on our current Conscious Sedation Record. In progress notes (on electronic record), please make a note to refer to further documentation on paper Conscious Sedation Record
Urine Specimen Collection
1. Click on Flowsheets tab and select ED Assessment and Care 2. Select Genitourinary, then Void Route, choose appropriate route
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3. Select Urine Specimen, Status. Choose appropriate options
4. Select Testing Type. Choose appropriate options
Visual Acuity Assessment
1. Click on Flowsheets tab and select ED Assessment and Care. Expand EENT
2. Use the Snellen chart to obtain the information to document in the Visual Acuity fields
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Wound Treatment/Ongoing Wound Assessment
1. Click on Flowsheets tab and select ED Assessment and Care 2. Right-click on row header, click on Add Parameter
3. Select Skin, then Wound #1, etc. … Can add up to 3 wounds, click Add and OK
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4. In time column, add column and document about the wound
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5. Ongoing wound care to be documented in additional time columns
Section: PEDS Documentation
Pediatric In and Out Catheter Using a Feeding Tube
1. Assessment and Care-Genitourinary 2. Urine Void Route 3. Click Catheterization, Intermittent 4. In Comments Document: Size of Feeding Tube, used for Intake and Output cath, Description of Urine (small amount of dark yellow urine) and patient’s tolerance. Include any patient teaching here
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Broselow Tape
1. Vitals Signs Document-Body Measurements 2. Document Estimated Weight according to Broselow, enter weight and then select weight calculation tape, pediatric 3. Specify Broselow Colour by right-clicking in the body measurement section, click modify row label and then enter colour of Broselow in the comments section
Central and Peripheral Capillary Refill
1. Assessment and Care-Vascular Section-Distal Extremity Check 2. Cap Refill - if normal, select 2 seconds or less 3. Cap Refill - if delayed, do not select either option and specify how many seconds in the comment box 4. Location - if wanting to specify central, enter in comments ‘central location’ 5. Location - if wanting to specify distal, select the appropriate location in the prewritten boxes
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Child – Breastfed, Bottle or Pedialyte Given
1. Intake and Output Flowsheet-Oral Intake 2. Add Parameter-Oral-Choose appropriate oral intake, click Add then OK 3. Breastfeeding is calculated in minutes per side, all other oral fluids is calculated in mL
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Fontanelle
On Assessment and Care – Skin, Fontanelle. Use free text box to add additional information as needed
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