Download Electronic Patient Record Manual Clinical EPR for Student Nurses

Electronic Patient Record Manual
Clinical EPR for Student Nurses
Kimberly Morency RN, BScN, MEd
08/08/2013
When working your way through this manual unless told otherwise by an exercise;
always use the patients assigned to you. You can find these patients on your Worksheet
for Classroom Training
Faculty of Nursing Clinical EPR (version 5.5 with ClinDoc) student training manual August, 2013
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DISCLAIMER: This document is prepared as an abbreviated manual for
students of the University of Manitoba Undergraduate Nursing Program
who will attend St. Boniface General Hospital as part of their clinical course
requirements. If discrepancies between the information contained herein
and the master copy produced by the St. Boniface General Hospital exist,
the master copy shall be deemed correct.
Acknowledgment is extended to The HISP team from St. Boniface General
Hospital and eHealth Manitoba for the materials from which this manual is
comprised
Please read your way through this manual, when you come across a
student exercise or anything highlighted in yellow it is time for you to use
the EPR training database found on every desktop in computer lab 390 (i.e.
pages 7-12 please read, and look at EPR to provide a point of reference.
Page 13 has a student exercise on it; this is when you would actually
complete the task on the EPR. When you are done the manual you will
complete your test called “validation exercises”
To summarize, don’t click on anything unless asked to do so in a student
exercise.
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Table of Contents
Section
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W1
W2
X
Y
Title
Page
Logging on Clinical EPR
General information
Find Patient
Patient Lists
Flag New Column
Assigned Nurse, Fall Risk, Patient Condition, Visitor
Status, Travel Mode
Viewing Results
Patient Location
Patient information
Allergies / Intolerance
Entering Height and weight
Health Issues
Visit history
Orders Tab
Viewing Orders Using the Options Panel
Add Specimen
Worklist Manager
Viewing tasks using worklist manager
Charting medication tasks on the worklist manager
Tasks Requiring Co-Signature
5
7
13
17
19
20
Clinical Documentation
Documents
Care And Assessment Flowsheet (CAFF)
Vital Signs Flowsheet
Clinical Summary
Patient Problems
59
61
65
71
72
73
22
28
30
31
36
37
39
41
42
44
45
50
51
58
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Troubleshooting
Usually, when you attend clinical at St Boniface, your Course Leader or CEF will
provide you with your USERNAME and PASSWORD once they get it from Kim
Morency. The first time you log on you will be prompted to change your password.
If you forgot or don’t know your password or have trouble accessing EPR, please
call:
Manitoba eHealth Service Desk at:
940 – 8500 (Press option 2)
-
OR –
Email Manitoba eHealth Service Desk at:
[email protected]
Do not call Kim unless the
service desk has directed you
to
PHIA
According to current PHIA legislation, each person is
responsible for maintaining security of patient information as well as ensuring that
only authorized personnel have access to patient information.
The following must be followed by all staff and physicians:
Users must always log in under their own user name and password (except in
training).
Users may not share their confidential password with anyone else.
Never let someone else use your security to access the EPR. This would be like
letting them sign your name on the chart.
Each time a user logs onto the EPR Gateway, the EPR application tracks who
accessed the patient charts and any changes that were made to
the patient data against the person who is logged in.
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A.Logging On
1. in Helen Glass Computer Lab (the process is different
than in at the hospital)
Click on the white and red “EPR client” icon
Click on “connect”
Leave the words
Allscripts and EPR
ACADEMIIC in their
boxes
In the password box
type the word
“training”
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Click on the Sunrise
enterprise gateway
Log onto clinical EPR using the
username and password supplied at
the bottom of your patients sheet.
Make sure your current patient list
is “training”
If it is not, click on the drop down
box and select training
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The first time you log into the
EPR Gateway, the screen will
appear as a blank grey
screen.
You will need to expand the
Application Sidebar by
clicking on the arrow at the
bottom left of the screen.
Once the Sidebar opens you
will need to click on the
application you wish to
open.
For student nurses, this
will be “clinical EPR”
This procedure will not have
to be repeated again.
***IF you get a message stating “your criteria for list retrieved more than allowed”
click OK
2. To Log On to the EPR gateway AT The Hospital (not at Helen Glass)
icon on the desktop. The My Citrix Apps
Double-click the My Citrix Apps
window opens.
Double Click on the EPR Gateway icon.
- OR –
Go to the Start button on your task bar located
on the workstation desktop.
Select My Citrix Apps and then select EPR
Gateway
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B. General Information
EPR Gateway Screen View
EPR Gateway is made up of five (5) sections: Breadcrumb Trail, Application Sidebar,
Gateway Toolbar, Main Content Area, and the User Notification Bar
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Application Sidebar
Allows the user to:
Switch between the current application and another
application easily (this is for users with more than one
application, student nurses only have access to the clinical
EPR application)
The QuickPick feature allows the user to:
Open an application in the Main Content Area
Choose a patient from a listing of 14 recently viewed patients
Close an Application
Sidebar arrow: click to expand or hide the sidebar
Gateway Toolbar
Provides the tools to set user preferences, and to suspend or close Eclipsys
Gateway and offers an on-line help.
Recently Viewed Patients
View and select a patient from a list that retains the last 14 patients viewed in
the past 24 hours
User Preferences
Change your password—the first time you log on you will be prompted to
change your password, for future changes go to the user preference icon and
click on change password.
Logoff / Shutdown EPR Gateway
Closes EPR Gateway and all EPR applications you currently logged in to
Help
Access on-line Help (Reference Guide) for the current application in the main
content area
Main Content Area (more information on following page)
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Breadcrumb Trail Tells you the current application and current tab you
are on.
User Notification Bar Displays:
Current user login name and role
Current date and time
Current environment
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Main Content Area: Toolbar (icons), Chart Tabs
Toolbar icons allow you quick access too many of the functions also found on
the menus.
Inactive icons will be grayed out. Some icons are active from any section of
the chart. Other icons are only active from certain sections of the chart. Icons
may be inactive if a patient is not selected, or if you are in a part of the chart
that does not have access to that icon.
Previous Patient: Displays the chart of the previous patient selected in the
patient list. Icon is only active if you have at least one patient selected and if you are not
currently viewing the first patient in the list.
Next Patient: Displays the chart of the next patient in the Patient List. This icon is only
active if you have at least one patient selected, and if you are not presently viewing the last
patient in the list.
Refresh Screen: Updates the patient list. Be sure to refresh often to ensure accurate
information on your patient list.
»Note: If you are logged in and new results come in on your patient, you will not see a
flag for new results unless you refresh your screen (or if you log off and back on).
Enter Order icon. Opens the Order Entry Worksheet to place an order.
Find Patient: Search for patients who are currently registered/admitted, or who are
discharged. Find patient by name, birth date, MRN or Visit ID.
Find Visit: Search for patient visits by patient name, your role, provider, location, service,
or visit status.
Enter Health Issue: Enter new health issues by accessing the Health Issue
Manager (ARO, ACP, HCD, Visit Reason and Infection Control information).
Allergies Summary: View the Allergies/Intolerances Summary View for the
selected patient or enter new allergies/intolerances.
Signature Manager: Sign and co-sign orders, tasks and documents
Worklist Manager: View a list of tasks that need to be performed for a patient,
and to indicate completion of tasks.
Flowsheet Manager: View or Add flowsheet data
Print Reports: Print or preview reports
Add Care Provider: Add yourself as the Student Nurse for a
selected patient, or group of patients.
Change Location: Assign the selected patient to a new location, or do a location swap
with another patient, or assign or clear a temporary location for the patient
More Header Info: Opens the expanded header allowing you to view more
detailed demographic information than is displayed in the standard patient header.
Calculator: Assists with calculations
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Chart Tabs
The Clinical EPR organizes patient information into a chart containing chart
tabs (sections), similar to a paper chart. Click on a chart tab to move to that
section of the chart
Chart Tabs
→→→→
»Note: A patient must be selected in order to access chart tabs other than the Patient List.
The Patient List Tab
The Patient List is the first screen that displays when you log into the Clinical
EPR. You can choose one or more patients on the patient list to view or enter
information on their chart
Orders Tab
Allows the user to view and modify existing orders for the selected patient(s).
You will learn more about the Orders tab in the Order Entry section.
Results Tab
Allows the user to view results for the selected patient(s). The following
results are available:
Lab results – Results from most labs (Biochemistry, Hematology,
Microbiology,
Immunology and Respiratory).
Diagnostic Imaging Results – X-Ray, CT scan, Ultrasound,
Echocardiogram and MRI.
Patient Info Tab
Allows the user to view or enter patient information for the selected
patient(s) such as allergies, height and weight, health issues and
demographics.
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Patient List tab toolbar icons:
When you are on the tab called patient list, these icons will display in the header. You
will complete student exercises later on in this manual that will help you get comfortable
navigating these icons
New Visit List: Create a visit list based on your role, location, provider,
service, visit status or orders.
Modify Visit List: You can make changes to your list according to the criteria
you desire.
Delete Current List: You may delete your current list if desired.
Delete Visit List: The Visit Lists for <Your Name> window appears showing
all your defined lists. You may select multiple lists you want to delete.
Flag New On: Will turn on Flag new for all selected patients. This will track
all new information on your patients when received.
Flag New Off: Will remove all flags and assist in resetting the flag new
features for your patient if you have been away for several weeks.
Select All Visits: Allows you to select all patients form your Current List.
Save Selected Visits: Allows you to create your own Special lists which are
then marked with an asterisk (*).
Remove Selected Visits: Allows you to remove one or more patients from a
Special list.
Select Visit List Column: You can define which columns to view in each of
your visit lists, except for temporary lists
Define Sort Order: Sort the Patient List by specific criteria (i.e., visit date,
admission date, etc.)
Save Sort Order: After defining a sort order, you can save a sort order
Reset Sort Order: After saving a sort order, you can reset a sort order to the
default.
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C. Patient Lists
Special Patient Lists are lists that you create that contain only the patients
you want on your list. They are working lists that you will maintain. They are
saved when you log off and are available the next time you log in. The lists
that you create are only visible to you.
An example of a special patient list would be a nurse creating a list of his/ her
assigned patients for the shift.
Student Exercise: Select your assigned patients (on your Worksheet). To
find “your patients”, click on the drop down arrow located beside current list,
and scroll until you locate the list (training room / Ward) indicated at the top
of your “Worksheet for Classroom training”
>>NOTE: Multiple patients can be selected from a patient list by holding
down the Ctrl key and clicking on each desired patient.
Click the Save Selected Patients button located to the right of the Current
List drop-down.
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The Save Selected Patients window will open.
Because this is the first list you have created, the New List Name option is
already selected.
Type YOUR NAME Assignment or list (i.e. if it were me I would type Kim’s
assignment or Kim’s list) in the New List Name field. Click Ok.
Your new list displays as one of the choices in the Current List field. Notice
that your list name is preceded by an asterisk (*), which distinguishes special
lists
Modifying Special Lists
Remember that you have to maintain the special lists that you create. Patients do
not automatically get removed if they are transferred or discharged.
Removing a Patient from a Special List
You may want to remove a patient from your list e.g. if they are transferred or
discharged, or if they are no longer your patient.
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Customizing the Patient List
The columns that display on the patient list can be customized to meet your
needs. There are specific columns that are pre-defined to display. You can add
or remove columns from a list, and change how they display if desired.
The changes that you make to a list only affect the list currently displayed. If
you wish to modify other lists, you must select each one individually and
make the desired changes.
The changes that you make to your lists affect how the lists display only.
When you print a list, the changes will not appear on the printout. The
printouts for patient lists are predefined reports and the columns that display
are standardized and cannot be changed.
Student exercise: Select the list you created *Kim’s Assignment from the
Current List drop-down.
Click on Select Visit List Column icon from the patient list tab tool
bar.
The Patient List Column Configuration window will open
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The columns that currently display on the patient list appear on the righthand side under Displayed Columns. The columns that are available to be
added display on the left-hand side under Available Columns.
Select assignment / coverage from the Available Columns list on the left
side of the window. Click on the Add>> button. The selected column will
move to the Displayed Columns list on the right side of the window.
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To change the order that one or more columns display, select the Visit List
Column icon. Click on the Displayed Column you want to move. Click on the
Move Up or Move Down buttons until the column is in the position you want.
Click on assignment / coverage on the Displayed Columns list Click on the
Move Up button until the column is below the Patient Name on the list.
Click on the Admit Date column on the Displayed Columns list. Click on the
Move Up button until the column is where you want it on the list.
Click on OK.
You can also
remove items that
you do not wish to
have on your
patient list
Take a minute or
two and set up
your list and
columns the way
you would like
them. As you do
this, please ensure
you have
assignment /coverage, falls risk, and visitor status in your visible columns, as
you will need these for a later exercise.
D. Find Patient on the Clinical EPR
Student Exercise:
View the visits for a patient named Wilmar Penner.
Click on the Find Patient
icon on the toolbar.
The Find Patient Window will open.
On the Basic tab, complete the following:
Last: Enter Penner (patient’s entire last name).
First: Enter Wil (first three letters of the patient’s first name).
Find similar sounding last names: Is pre-selected in the Search
Options.
Gender: Leave blank.
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Click on the Search button
Click on desired patient. You must click on the patient’s name, even if there is
only one showing.
Click on the Show Visits button.
If you want to add this person to your special list, pick their current visit,
double click on it and then save to your list.
For today’s exercises, you do not need to add Wilmar, he and other patients
you use later on will automatically be saved to a temporary list.
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E. The Flag New Column :
Please read this for information purposes, do not touch the flags while
you are completing your EPR training
Flags appear in columns on the patient list indicating that there is new
information received since you last acknowledged reviewing information on
this patient.
Care providers who are assigned to patients on the system (e.g. physicians)
can leave the Flag New feature turned on at all times and they will be flagged
when new information is received.
Care providers who are assigned patients for one or more shifts (e.g. nurses)
can reset the Flag New feature to track all new information on patients from
the time they turned the flags on. This will prevent older information from
being flagged as new (i.e. if a patient has been on ward for a month but this
nurse has not looked after the patient for several weeks, then all of the
patient’s information would be flagged as new. If the nurse turns the flags off
and on, then only new information will be flagged.)
Select the icon Flag New Off
from the patient list tab tool bar.
Select the icon Flag New On
to turn the flags back on.
You have now reset the flag new feature for your patient
Any results received after you reset the flags are considered NEW.
The Check Orders is present for nurses and ward clerks. It is a quick way to
see if patients have any new flags in the New Orders, New Alerts, To Sign or
Orders Pending
Check Orders Green flag
new orders may require acknowledgment, review, or
further actions. Also triggered when the order status
changes from
unverified to verified.
Check Orders Red flag
new orders may require acknowledgment, review, or
further actions. If the flag is red, it indicates that at
least one of these orders is STAT.
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The ward clerk and charge nurse will use the Check Orders flag to
monitor when new orders are present that may require further
action. When they clear the flag it is cleared for everyone
F. Assigned Nurse, Falls Risk, Patient Condition, Visitor
Status and Travel Mode
There are five columns on the Patient List tab that can be updated on the
same screen. They are the Assignment/Coverage, Falls Risk, Patient’s
Condition, Visitor Status and Travel Mode.
Travel Mode information: Select the patient’s travel mode from the list of
options; the staff will then transport patients according to their unique travel
mode.
Assignment/Coverage Column: Lists the first name of the nurse assigned to
the patient, as well as the first name of the nurse assigned for break coverage.
The goal of the process is to communicate nursing assignments to all
clinicians and administrative support persons who have access to the Clinical
EPR.
Falls Risk Column: Select the patient’s fall risk status from the available list
using your Falls Risk Assessment Form. This information will then
communicate to all staff the patient’s risk for falls.
Patient’s Condition Column and Visitor Status Column: List the patient’s
current condition and their visitor status. This information is used by Patient
Inquiry staff when responding to callers or visitors.
Student Exercise: Complete the following for all of your patients except #5
On the patients list tab, scroll to one of the following columns:
Assignment/Coverage, Falls Risk, Visitor Status, Travel Mode or the
Patient’s Condition column and double click in the cell
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The
Miscellaneous
Data
Maintenance
window will
open
Kim
Complete the fields as follows:
Patient’s Condition: Click on the arrow and select desired condition “good”
from the drop down list.
Visitor Status: Click on the arrow and select the desired visitor status ”RV”
from the drop down list.
Travel Mode: Click on the arrow and select the desired travel mode
“wheelchair” from the drop down list.
Falls Risk: Click on the arrow and select the fall risk status “not at risk” from
the drop down list according to the Falls Risk Assessment Form.
Assigned Nurse: Enter your name and designation ( SN )
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G. Viewing Results
The Results Tab
The EPR has features available to assist you in filtering results to display only the ones
that you are interested in at a given time.
A filter lets you focus on selected results by “filtering out” other results.
The filter icon and message will display at the top of the Results Grid when a filter
is in use. This reminds you that not all results are being shown for this patient.
Student Exercise: Find the patient Zen Zimmerman. Now select the Results
tab
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You want to see all of the patient’s results, so ensure you have
selected “all available charts”
Make sure you have selected the appropriate date range, do you
want only the past few days’ results, or for the entire stay?
While in training today, keep it on start of this chart (click on
the arrow it will give you the option to choose start of this chart)
As students, keep your filters off, so maintain the no result
section filter
How do you want to see your results? Summary, Report by
order, or do you want it trended and graphed? Depending on
your patient care area, your CEF will provide you with some
guidance on his / her preferred view.
Please take a few minutes and review each of
the four display view options, and note the differences between
them.
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Sample Result Screen: Report by order view
This is a report of a Complete Blood Count (CBC)
Result Icons
Icons
Description
Abnormal low or high numeric result (depending on direction of
arrow)
Very abnormal low or high numeric result (depending on direction of
arrow)
Abnormal test result
Very abnormal test result
Result has un-displayed textual data. Click icon to display
complete text.
The value of the result has been changed. Click icon to view the
result’s history
A clustered result, for results that have repeated components
(e.g. microbiology reports with organisms, followed by sensitivities)
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New Results
Patients with new results will have a flag in the New Results column on the Patient List
tab, or you can go to the Results tab. You will learn how to do it both ways.
Yellow Flag:
Result with No Abnormality
information (i.e. no reference range).
Result may be Normal or Abnormal.
Red Flag:
Abnormal test
results are
posted.
New Results can be accessed by double clicking on the flags that display in the
new result column on the Patient List tab.
Student Exercise:
Go back to the patients list tab; change your current list to Training A (or
N1017)
Scroll down and select the Patient Field; Franklin:
Double click on the flag in the New Results column.
The New Results window will open.
Scroll up to view all of the new results
The Clear Flag button on this screen acknowledges that you have reviewed
the result(s). In clinical you would Click on it to close the New Results
window, and clear the flag from the patient list tab. DO NOT DO THIS NOW,
just x out of the window.
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Student Exercise:
We will use Field; Franklin again to learn how to review the lab values via the
results tab. This is just another way to access the new results.
Select Faith,
Click on the Results tab.
Click on the View icon
window will open.
and select New Results. The New Results
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Scroll up to view all of the new results.
Click on the Don’t Clear Flag button to close the New Results window.
o In Clinical you will click on the clear flag window. This
acknowledges that you have reviewed the result(s).
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H. Patient Location
When a patient’s location changes during their visit, this new location is entered
on the EPR. Accurate patient locations are important for directing visitors and
staff to the correct place, for delivery of meals to the correct location, for
removal of medications from Pyxis, for statistics, etc.
After you select the desired patient on the Patient List tab, click on the
Change Location icon on the toolbar. This icon will allow you to:
Change the patient’s assigned location (i.e. transfer them to another
empty bed, or to another clinic/area).
Do a location swap with another patient (bed swap/bed exchange). This is
used to swap the locations for two patients that are in occupied beds.
Enter or clear (remove) a temporary location. Temporary locations are used to
indicate the location of a patient if they are temporarily moved from their
assigned bed (e.g. to the Operating Room, to Xray, to Dialysis, etc.).
The person who is transporting the patient is responsible for entering the new
temporary location. The location is entered in the EPR when the patient arrives at
the temporary location. Porters, health care aides, unit assistants, RNs, or
students may do this
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Student Exercise Your patient is going to XRAY, this is a temporary location,
enter this in the EPR
From the Patient List tab, choose your patient #2.
icon on the toolbar. The Location
Click the Change Location
window will open. Note the patient’s current assigned and temporary
locations (if any), displayed in the Current Information section.
In the Temporary section, complete the fields as follows:
New Location: click the drop down arrow and select SBGH-Oupt
DI-Xray from list. This location is used for any patient going to
Xray (Inpatient or Outpatient).
Effective: Defaults to Now. Click OK.
Look at the patient information bar on the patient information
tab. You will see your patients temporary location is in brackets
beside their regular location.
Your patient is now back from x-ray Click on the change location
icon again. In the Temporary section, click the Clear Current
Temporary Location checkbox and click OK, to indicate that the
patient has returned to the assigned location
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I Patient Information
A variety of patient information can be viewed and/or entered on the Patient
Info tab.
Select your Patient #1 on the Patient List tab.
When you click on the Patient Info tab, the
window has two sections on the left to
select the information that will display on
the right hand side of the screen.
Summary Views: Click on an item in the
Summary Views lists to display the
current information for the selected
patient. You cannot enter new information
using the Summary View.
Data Entry: Click on an item on the Data
Entry list to enter new information or
modify existing information.
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Allergies/Intolerances
Allergy/Intolerance information is collected and recorded to support clinical
decision making.
The clinical provider collects and records Allergy/Intolerance
information during the patient assessment.
The patient describes Allergies/Intolerances to the clinical provider,
who records the information into the Clinical EPR.
The attending provider confirms Allergies/Intolerances and marks
them as reviewed in the Clinical EPR, and inactivates/discontinues
Allergies/Intolerances as necessary. Allergy/Intolerance information
needs to be updated as required throughout a visit.
Definitions for Allergies and Intolerances
RNs, nursing student, midwives, physicians, residents and clinical clerks will
collect and enter Allergy/Intolerance information
Allergy: Indicates an immune-mediated response to an agent (drug, food,
environmental). Allergy information is usually based on reports by the
patient or family member of past experiences.
Intolerance: Indicates a usually predictable or dose-dependent effect of a
drug that is not the principal effect for which the drug was chosen; the effect
may be desirable, undesirable, or inconsequential; for example, nausea from
antibiotics.
A patient can also exhibit intolerance to food and environmental agents.
Intolerance information is usually based on reports by the patient or family
member of past experiences.
J. Allergies/Intolerances
To view patient allergies, from the Patient List tab
Choose Jane Jackson on A7 West.
Click on the Allergies/Intolerances Summary icon
(Itchy man).
The Allergies/Intolerances Summary window will open.
The current Allergy/Intolerance information (Allergies/Intolerances
and Allergy/Intolerance comments) will display.
You can see that Jane has several allergies.
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Select your patient patient #2 and click on the itchy man
you will get one of two windows:
The Allergy Type window if the patient
selected has no allergies/intolerances
information entered yet, or if they have an
entry of No Known Allergies or Allergy Status
Unknown.
The Allergy/Intolerance (Adding New)
window if the selected patient already has an
Allergy/Intolerance entered on the system.
Your patient #2 is not sure of any Allergies/Intolerances that he/she may
have. Enter this (status unknown) in the EPR.
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Your patient’s (#2) family has come to visit. You discuss your patient’s
allergy/intolerance status, and it is confirmed that he or she has no
allergies/intolerances. Your patient’s allergy/intolerance status is no longer
unknown; you now know that he or she has no known allergies/intolerances.
Enter this information in the EPR by selecting the no known allergies radio
dial.
The Modified History icon
appears, this now displays because you have
changed something on the allergen since it was first logged against the
patient
You discover that your patient #3 is allergic to penicillin. Enter the following
information. See next page for a description of each field
Select Enter New
Allergy/Intolerance.
The Allergy/Intolerance (Adding New) window displays, select Allergy.
The Type field defaults to Drug.
Click in the Allergen field and type peni.
The allergen list is sorted with all the allergens that start with “peni,”
displayed at the top of the list.
Scroll down the list and select penicillin.
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Field
Category
Type
Status
Allergen or
Product
Reaction
Severity
Description
Onset Date
Confidence Level
Information
Source
Confirmed By
Entered
Last Modified
Description
Allergy or Intolerance
The type of allergy/intolerance. Options include:
Airborne – entry of airborne allergies (e.g. pollen, dust mites).
Drug – entry of a specific drug or agent name (e.g. Septra, furosemide).
Drug Category - used when the patient reports an allergy to a drug class (e.g. Sulfa
Drugs, beta blockers, iodinated radio contrast).
Food – entry of food allergies and food dyes.
Skin Contact – entry of skin contact allergies (e.g. adhesive
tape, detergents, latex).
Stings Bites – entry of sting bite allergies (e.g. Bee sting, spider bite)
The status of the allergy (active or inactive).
The name of the allergen (if you are entering an intolerance, the field name changes to
“Product”) is selected from the list. The lists are specific to the allergy type chosen. If
the desired allergen is not on the list, select Other from the allergen list and then enter
the name of the allergen in the Description field.
Click on the Add Reaction button to add one or more reactions. On the Reaction
Details window, choose the desired reactions from the list. If the desired reaction is
not on the list, select Other and type the reaction in the Description field.
To select a severity for the reaction, click the down arrow in the severity column next
to the selected reaction. Entering the severity of the reaction is not mandatory, but if
known is recommended.
Enter a description of the allergic reaction or intolerance (optional). Also used to
enter allergens or reactions that were not on the list. If information is entered in the
description field, then the information icon displays when viewing the
allergy/intolerance.
<<note: The allergen/product must be selected from the list for
allergy checking to take place during order entry.
Enter the onset date for the allergy, if known. Select M/Y to enter the month and year,
or select Full Date to enter a date using the calendar.
Enter a confidence level for the allergy/intolerance (optional).
Enter the source of the information concerning the allergy (e.g. Family member,
medical record, patient).
Enter the name of the person who confirmed the allergy (optional). Can click the ME
button if you are the person confirming the allergy/intolerance.
Allergies/Intolerances are confirmed by the attending provider.
The system fills in the person who created the allergy/intolerance and the date/time.
The system fills in the person who last modified the allergy and the date/time.
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Select all reactions that apply.
Click the checkboxes next to Diarrhea and Short of breath.
Choose the
severity of
reaction from
the Severity
column;
Choose Severe
for Short of
breath and
Moderate for
Diarrhea.
Click OK.
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The attending provider accesses the patient’s chart on the Clinical EPR and
reviews and validates the Allergy/Intolerance information recorded with the
patient.
Allergies/Intolerances will be marked as confirmed by the attending
provider, or will be inactivated if required.
A message in the patient header will read “Unreviewed Allergies” if the
patient’s allergies/Intolerances have not yet been reviewed by the attending
provider for this visit.
K. Entering Height and Weight
Height and weight will continue to be entered on the paper chart.
Only the most recently entered height and weight are stored on the
EPR.
When we start using Clinical Documentation on the EPR, then previous
values will be stored on the EPR and trends can be viewed.
The EPR can automatically calculate the patient’s body surface area
(BSA) if height and weight information is entered.
Other types of calculations such as BMI can also be displayed.
Height and weight are required for specific types of tests or treatments
(e.g. pulmonary function studies), drug dose calculations, body surface
area calculations, or energy requirement calculations.
In completing your assessment of your patient #1, you need to document
their height and weight on the EPR.
With your patient #1 selected, click
the Patient Info tab.
In the Data Entry section: Select
Height/Weight from the list. The
Height/Weight window
opens.
>>NOTE: Height can be entered in
cm or ft and inches. Weight can be
entered in kgs or in lbs and ozs. The
system will convert the values for
you.
Height: Enter the current height of
168 in the cm field
Weight: Enter the current weight
of 76 in the kg field.
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L. Visit History
You are interested in obtaining previous visit information for Edith Edgy.
Find the patient Edith Edgy.
Click on Patient Info tab.
From the Summary View window, click Visit History.
Click the Filter test link in the lower right corner of the window.
The Visit History Filter window opens.
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From the Visit Type/Care Level field, click Recurring/Ambulatory Care.
Click OK.
Only the
recurring and
ambulatory
visits now
display
To view more
information about a visit, click on the visit and then click the Details button.
The Visit Details window opens, displaying additional information about that
visit.
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N. Orders Tab
Attending providers (Doctors / nurse practitioners etc) or their designate will
enter orders directly into the EPR whenever possible. Selected roles can also
enter orders on behalf of the attending provider/designate (e.g. verbal or
telephone orders).
After orders are entered for a patient, they will display on the Orders tab. The
Orders tab will maintain information about all orders that have been entered
for the patient, any changes to these orders, and their status.
The orders tab has the
option to add filters, DO
NOT use filters as a
student. The green filter
icon indicates the order
list is not filtered and all
orders appear
Icons Used in the
Orders Tab:
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Add Specimen: will be used to document specimens (i.e., urine, blood, sputum)
collected by the lab as well as those collected by the unit for inpatients. The Add
Specimen function will not be used for outpatients.
Approve/Verify: if you have the necessary rights you can view the order items to be
verified.
Do NOT use Copy/Reorder function to reorder. This leaves the previous order
active, resulting in duplicate orders
Discontinue/Cancel order. Discontinue orders that are no longer required.
Discontinue/Reorder order. Do use the Discontinue/Reorder function to reorder.
This discontinues the previous order, avoiding duplicates.
Modify order. The Modify function icon is only used to modify an order to document
consult notification, or to acknowledge a consult order
Reinstate order. Reinstate cancelled or discontinued orders.
Release order. Release one or more orders that are currently on hold.
Sign icon: allows you to sign one or more orders.
Suspend order. One or more active orders can be stopped temporarily while the
order is not required for the patient due to a change in clinical condition.
Unsuspend orders that are still required.
Other Actions: from the arrow menu you can select acknowledge orders, mark an
order as reviewed.
Maintain Order Set: from the arrow menu you can perform various maintenance
actions for an order set.
View: from the arrow menu you can view new orders, history, details and order set
details etc…
O. Viewing Orders Using the Options Panel
You want to view all of your assigned patient #2‘s orders since admission.
Select your assigned patient #2
Click on the Orders tab.
In the Options panel on the left side of the screen, note these fields:
Chart Selection: Orders from this chart only.
Date Range: From: Start of This Chart.
Display Format: By Department.
Filters: Status/Priority: Defaults to No Status/Priority Filter. This
would show all orders for your patient, including discontinued orders,
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orders on hold, etc. You would change this to All Active Orders if you
only wanted to see orders that are currently active.
To view the details of an order, double-click on any one of the
displayed. The Order Form displays, showing the order details
You notice icons on your patient’s list of orders that you don’t know what
they mean. You want to look up a list of the icons that can display on the
Orders tab.
While on the Orders tab, click on the Launch Active Application
Help icon in the upper right hand corner of the window.
The About Viewing Orders window opens.
Click on the links for Orders Tab Toolbar or Orders Tab Orders Grid
and you will view order icons with definitions.
Use the scroll bar to scroll through the list to find the icon that you
need help with. When you are finished with the help screen, click on
) button on the help window to close it (be careful not
the (Close
to click on the close button for the EPR, or you will have to log in
again!).
Status of Lab Orders
The order status helps you track the progression of the lab orders.
Lab orders will display with an order status of Pending Collection
when the specimen is awaiting collection
When the Add Specimen function is completed for an order, the order
status will change to Collected on the Orders tab
Approximately 90 minutes later, the EPR will auto-complete orders
with a status of Collected and the status will change to Specimen to
Laboratory
When the result comes across to the EPR from the Lab system, it
creates a new order on the EPR with a status of Final Result (i.e. there
will be duplicate orders for every lab order on the EPR). Using filters
on the Orders tab, you can avoid viewing these duplicate orders.
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P. Add Specimen
The Add Specimen function is used to document that one or more specimens
can
have been collected for one or more lab orders. Add Specimen icon
be selected to document specimens collected by the lab as well as those
collected by the unit for inpatients
You have just collected a blood sample (Specimen) from your patient. A CBC
order was already placed for the patient. You need to document on the EPR
that the specimen has been collected.
Select your assigned patient # 2
Click on the Orders tab.
Click on the add specimen icon
.
Choose the specimen
type for which you have
collected the specimen.
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Complete fields as follows:
Specimen Type: Defaults to Blood in this case, as there is only one specimen
type for the selected order (CBC). If there could be different types of
specimens for a test, then this field will be blank and you will have to choose
the appropriate type of specimen from the drop-down list.
Orders: Click the checkbox beside the CBC order.
Collection Date & Time:
Collected Over Time: Leave unchecked. If the specimen has been
collected over time (for example, 24 hr urine), you would select the
Collected Over Time check box. You can then specify the starting and
ending dates and times for collection.
Start Date & Start Time: Defaults to the current date and time. Change
to the actual collection date and time if different than the current date
and time. For collected over time specimens, enter the date and time
that the collection started.
End Date and Time: This field will only be active if the Collected over
Time checkbox was selected. For specimen collected over time only,
enter the date and time that the specimen collection ended.
Q. Worklist Manager
The Worklist Manager can be used to both view and document tasks (Like the
paper chart’s Medication Administration Record or MAR).
Users who do not administer medications may be able to view the Medication
Worklist, but will not have access to the documentation functions. Users who
administer medications will be able to both view and document medications
using the Worklist Manager.
Options include:
Mark tasks as done or not done (chart medications)
Document on the medication task form the required details of the
administration such as dose administered for variable dose orders,
route, observation, site
Schedule or reschedule tasks
View any changes to the task
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Student Nurses will:
View the Worklist at the start of their shift to see the medications to be
given for each of their assigned patients
View the Worklist periodically throughout their shift to see any
updates to medication orders, or new medication orders.
The new orders column on the patient list will also be monitored for
flags indicating new orders on patients
View the medication Worklist when preparing medications
Take a computer with you when administering medications.
Use the Worklist to check the 5 rights prior to administering the
medications
Document administration of the medications immediately on the
Worklist at the bedside
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Viewing the Medication Worklist
Select your assigned patient #3 from your Worksheet and click on the
Worklist Manager icon
to open the Worklist Manager.
The Medication Worklist for the currently selected patient displays.
You may wish to make your Worklist window bigger, or to move it so
that you can see information on the patient list.
To move the Worklist window, move your cursor to the blue title bar
for the Worklist Manager window and hold down the left mouse button
to drag the window to where you want it.
To enlarge the Worklist window, either:
Move your cursor to the bottom right-hand corner of the Worklist
Manager window. Cursor turns into a double arrow. Hold down the left
mouse button and drag the window to enlarge it slightly, and still be
able to see the patient list to switch between patients.
- OR –
Click on the Maximize button on the Worklist Manager window. The Worklist
will take up the entire screen.
To resize columns on the Worklist, move the cursor to the edge of the column
until the cursor becomes a double arrow, then drag the column to the desired
width. This may be required to display information
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Pharmacy Verification
When a medication order is first entered, it will display on the Worklist and
on the Orders tab with the icon
, which means the order has not been
verified by Pharmacy. All medication orders are sent to the Pharmacy
computer system (Centricity).
Pharmacist reviews and verifies the medication order
Verified order flows back to EPR - the Rx icon is removed
If pharmacist has questions about the order, they contact the
prescriber and discuss the order. The order may stand or be
discontinued and ordered correctly as per current practice
Pharmacists may enter orders on behalf of the prescriber
Pharmacists are available 0730-2330 hours to verify medication orders
Between 0730 – 2330 hours (Pharmacy open), only STAT/urgent
medications should be given prior to Pharmacy verification. Other
medications should wait until Pharmacy has verified the order
Between 2330 – 0730 hours (Pharmacy closed), medications may be given
prior to Pharmacy verification as per current practice
Nurse must check that the dose ordered is appropriate (in addition to
checking for allergies and the 5 rights) before med administration, if
the order was not verified by Pharmacy
Orders will not appear on Pyxis until they are approved by Pharmacy.
As per current practice, Stat and urgent meds can be removed from
Pyxis using override. When Pharmacy is closed, all meds can be
removed from Pyxis using override.
icon on the
>>NOTE: IN TRAINING all medications will display the
training system as we do not have a pharmacy at the Helen Glass Center to
interface with
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R. Viewing Tasks using the Worklist Manager
It is the start of your shift and you need to review the medications ordered for
your assigned patients
Select the patient list you created earlier called My assignment. Click on patient
#3 and do the following
Click on the Orders tab.
Click on the Worklist Manager icon
opens
The Worklist Manager window then
Always check the name of the patient on the Medication Worklist. Note
the patient allergies. Ensure that the following settings are in place on the
Worklist:
Task filter: You are working an 8 hour shift. Select All
Medications This Patient 8 hours from the drop-down list.
Scheduling: Defaults to All.
Status: Defaults to All.
From and To dates and times: Defaults to 90 minutes prior
and 30 minutes after the end of the shift selected in the task
filter.
Review the patient’s medication orders. Scroll as required to see all of your
patients medications, or you may choose to resize the screen to make it larger
Right-click on a medication on the Worklist.
Select View from the menu.
Select Order Details from the view menu.
The Order Form opens
Review the details of the order.
Click on the Close button when you are finished reviewing the order.
If you are logged in for a period of time, click on the Refresh icon on the
Worklist window. This will update the Worklist with any new information,
including new medication orders or new medication tasks charted.
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S. Charting Medication Tasks on the Worklist Manager
Medication/Intravenous tasks are charted on the Worklist (known as the
Medication Administration Record or MAR on a paper chart).
Only intravenous solutions that contain additives will appear on the Worklist.
To chart individual medication/intravenous tasks:
right-click on the cell for the time the task is due
A menu appears with various options.
Select the desired option from the menu.
Mark as Done: Document that a task has been completed by
you (i.e. sign for medications)
Mark as Done by Other: Document that a task has been
completed by another care provider (charting on behalf of
another care provider…don’t do this)
Mark as Not Done: Document that a task was not performed
(used only if the patient will not be receiving the medication)
Medication Administration (Task) Form
A Task Form is attached to the medication or intravenous task. When you mark a
task as done, the Medication Administration (Task) form opens. It gives the user
the ability to document required details of the administration such as:
The actual administration time, if different than the time displayed
The actual dose given for variable dose orders (dose range ordered)
Route administered for orders with more than one route option given
Body site for intramuscular and subcutaneous injections
Medication mixture label #/ or lot # (e.g. for immunizations). The bag
number may also be recorded here
Physiologic parameters (observations) such as heart rate, BP, blood sugar,
etc.
Name of co-signature, for medications that require a 2-nurse check. The
next time the co-signer logs into EPR & views the patient list for the entire
unit, he/she will see a flag in the To Sign column for that patient
Patient’s own meds used, or patient or family administered medications
Patient’s self-administered (bedside) medications restocked
>>NOTE: All fields marked with a red mandatory icon
require information.
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Overdue tasks: Best practice is to mark tasks as done immediately following
completing the task (take a computer with you for med administration and chart
at the bedside).
If a task is purposely not done (medication is being held), it should be
marked as not done within the hour that it was due.
If you will be giving a medication late, leave the task as overdue and
mark it as done when it is given.
Tasks become overdue if more than one hour has passed since they were
due and they have not been charted. The task description cell and the
overdue scheduled time cells turn red. Once the overdue task cells are
charted, the colour changes from red back to its previous colour.
If you see the hour glass appear, this means that the EPR is processing the
last entry. Do not enter any more information on the Worklist until the
hourglass disappears.
You have given your patient’s sodium chloride 5% eye drops in both
eyes. You now need to document this on the Worklist by doing the following.
Tasks will be yellow if they are scheduled tasks that are ordered with a standard
frequency.
Select your assigned patient #3 (from your worksheet).
Click the Worklist Manager icon from the toolbar. Always check the
Worklist to ensure that the correct patient’s Worklist is displaying. Note
the allergies listed on the Worklist.
The sodium chloride 5% Eye Drops Task Description is shaded yellow to
indicate that it is a scheduled task (has pre-defined administration times).
The time cells when the task is due are also shaded yellow and have the
pending icon displaying. Since this task is due every hour, the time cell for
each hour is shaded yellow with the pending icon (unless the task is
overdue i.e. you are late charting, at which point it will be red)
On the row for the sodium chloride 5% Eye Drops task, locate the cell
closest to the current time. Right-click on the cell and choose Mark as
Done from the menu.
Review the information on the form to ensure it is correct and complete as
follows.
o Administered At: default to the current time. Edit the time to the
actual administration time if it is different than the time displayed.
o Dose Given: has a red mandatory icon , indicating required
information, enter “1”
o Click the OK button to close the task form.
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The time grid cell that was formerly yellow is now white with a checkmark
and the dose administered (due to the variable dose ordered). Note 1d…
(for 1drop) displays in the time cell. Hover your cursor over the time cell to
display the full description.
Click the Refresh icon
on the Worklist.
>>NOTE: If the scheduled task had no more pending occurrences during the
current shift you are displaying, then the task description cell would be white
(i.e. there are no more times that this task is scheduled to be given for this time
period).
Your patient #3 complained of pain and you have given them acetaminophen,
which was ordered every 4 hours PRN for pain. You now need to document this
on the Worklist by doing the following:
Tasks will be magenta if they are ordered as PRN with a standard frequency.
Always check the Worklist to ensure that the correct patient’s Worklist is
displaying. Note the allergies listed on the Worklist.
The acetaminophen Task Description is shaded magenta, indicating a PRN
task. The time cells have a magenta trough that starts at the earliest time
that the task may be administered.
In the row for the acetaminophen task, right-click in the cell with a
magenta trough that is closest to the current time. Select Mark as Done.
Right-click on desired time cell in the trough
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Review the information on the form to ensure it is correct and complete.
Edit the time to the actual administration time if it is different than the
time displayed. All other fields have been pre-filled from the order. If any
fields were required, there would be a red mandatory icon in the fields
you must complete. For this order there are no red asterisks. We decide to
record our patient’s pain scale score.
Enter Pain scale 8 in the Physioloigic Parameters Other field. This is
optional. Click the OK button to close the task form.
o The Task Description cell is now white with a checkmark. The time
grid cell that was formerly a magenta trough is now white with a
checkmark and the initials of the user currently logged in.
Click the Refresh icon
on the Worklist. The Task Description changes back to
magenta, with a new magenta trough starting 4 hours from when you marked
the task as done (the next time period that the medication can be given).
You have given the furosemide injection ordered for your patient #3. You
now need to document this on the Worklist by doing the following.
Tasks will be green if they do not have a specific time e.g. a med to be given once
without a specified time.
The furosemide Task Description is shaded green to indicate that it is a
variable schedule task (task without a scheduled time e.g. to be given
once).
On the row for the furosemide task, right-click in the cell with a green
trough that is closest to the current time. Select Mark as Done.
Review the information on the form to ensure it is correct and complete.
Edit the time to the actual administration time if it is different than the
time displayed. All other fields have been pre-filled from the order. If any
fields were required, there would be a red mandatory icon in the fields
you must complete. For this order there are no red asterisks. Click the OK
button to close the task form.
The Task Description cell is now white with a checkmark. The time grid cell
that was formerly a green trough is now white with a checkmark and the
initials of the user currently logged in.
Click the Refresh icon on the Worklist. This medication was ordered to be
given once only, so the Task Description remains white indicating it is
completed. This task will remain on the Worklist until the end of the shift
that you selected in the task filter. It will then drop off the Worklist for the
next shift, but can be viewed if the time filter is changed back to the
administration time.
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You have changed your patient #3 intravenous bag and tubing, and need to
document this on the Worklist, do the following
Tasks will be cyan if they are continuous (administered on an ongoing basis).
The KCL 20 mmol/L Dextrose 5% NaCL 0.45% Task Description is shaded cyan to
indicate that it is a continuous task. The time cells have a solid cyan coloured bar.
On the row for the KCL 20 mmol/L Dextrose 5% NaCL 0.45% task, rightclick in the cell that is closest to the current time. Select Mark as Done.
This form had different time fields than the previous forms. Do not edit
the Administered From fields. Edit the Administered To fields to indicate
the time a change occurred.
Select the New Syringe/Bag Hung and Tubing Changed check boxes to
indicate that you have changed these
Click
OK.
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>>NOTE: You can document multiple times in the same time cell. If more than
one entry has been made in the same time cell, then “…” will display in the time
cell. If you set the By filter on the Worklist to Task Actual, then each time you
have marked something as done will display in a separate cell.
One or more of your patient #1 tasks is overdue (red). This means you did not
Mark as Done when you gave it (turns red within an hour of the time the
medication was due). Correct that by doing the following
Select an overdue task on any of your patients (if there are any), where the cell is
red.
Right-click on the red cell and select Mark as Done from the menu.
Review the information on the form to ensure it is correct and complete.
Edit the time to the actual administration time. All other fields have been
pre-filled from the order. If any fields were required, there would be a red
mandatory icon
in the fields you must complete. Complete any
required fields.
Click OK
The Task Description cell is now white with a checkmark. The time grid cell that
was formerly red is now white with a checkmark and the initials of the user
currently logged in (Debbie Jackson).
Click the Refresh icon on the Worklist. If there was only one task that was
overdue, then the Task Description will change back to yellow. If the Task
Description remains red, it means there are more instances of the task that are
overdue. The Task Description will remain red until all overdue task instances for
that medication have been charted.
Your patient #3 is off your unit for a test and they will not be available for their
Sodium Chloride 5% eye drops to be given. You need to document this on the
Worklist.
The Sodium Chloride 5% eye drops Task Description is shaded yellow to
indicate that it is a scheduled task (has predefined administration times), or
red if it is overdue (more than an hour since it
was due).
On the row for the Sodium Chloride 5%
eye drops task, locate the cell closest to
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the current time. Right click on the cell and choose Mark as Not Done
from the menu.
Reason: Select Patient not available from the drop-down list.
Click OK.
The time cell will have the red X icon X, indicating that the medication was
not given, as well as the initials of the user currently logged in. Hover your
cursor over the cell with the red X and note the description that appears.
T. Tasks Requiring Co-Signature
When marking a task as done, if a double check was required, the name of the
person who provided a double check for either medication preparation or
administration is entered in the Co- Signature field (usually your CEF).
The Co-Signature field will have a mandatory icon indicating it is a
required field for selected medications on the High Risk Medications list.
(See the Medication Administration Policy and Procedure).
The Co-Signature field on the medication task forms is used for
documentation for two person visual verification, as specified in the
Medication Administration Policy and Procedure.
The Co-Signature field is an optional field for medications that do not have
a red asterisk in the field. It can be completed when desired for any
medication.
>>NOTE: For neonates, all medications are double checked by another nurse.
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The nurse will enter the name of the nurse who completed the double
check in the cosignature field, even if it does not have a red asterisk.
Student nurses require a Co-Signature for all narcotics and controlled
drugs. There are other medications such as insulin that always require a
two nurse check. They must enter the name of the nurse who performed
the verification with them. The field will not have a red asterisk, as it is not
required for RNs to have these medications co-signed.
You have administered your patient’s morphine and need to document this on
the Worklist. You need to indicate the name of the person who performed the
two person visual verification with you. Please do the following:
Select your assigned patient #1 (from your worksheet).
Click the Worklist Manager
icon from the toolbar. Always check the
Worklist to ensure that the correct patient’s Worklist is displaying. Note
the
allergies listed on the Worklist
On the row for the morphine, right-click on the scheduled task cell closest
to the current time.
Select Mark as Done from the menu.
Complete fields as follows. All required fields indicated by the red
mandatory icon:
Dose Given: Enter “” given in the Dose field.
Click on the icon beside the Co-Signature field.
This is where you will document that your CEF Dan Jones (as
explained on the next page) was the nurse who provided the twoperson verification for the morphine.
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The Co-Signature window opens.
Complete the fields as follows:
Co-Signature: Select Other (ensure you complete this step, many students
leave it on current provider, which is doctors or Nurse Practitioners, you
need to choose other as this is where nurses are.
Type Jones (the last name of your CEF who witnessed medication
preparation).
Select Jones, Dan from the list of users that displays.
Click OK to close the Co-Signature window.
Click OK on the task form once you have completed all of the required
fields.
The
icon displays on the Worklist, indicating that a signature is
required.
The next time Dan logs into EPR & views the patient list for the entire unit,
he will see a red flag in the To Sign column for that patient.
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U. CLINICAL DOCUMENTATION (CLINDOC)
Clinical documentation is a component of the EPR used to document/chart and
communicate specific patient health information. Clinicians record patient’s health
details such as diagnosis, assessment, treatment, nursing care, procedure, routine
observations, and progress.
Clinical documentation is designed to:
Improve access to patient information
Coordinate patient care across locations and departments
Support critical decision-making
Reduce duplication of data entry
Improve patient outcomes and clinical performance
The Documents, Flowsheets, and
Clinical Summary tabs make up
ClinDoc
ClinDoc Glossary of Terms
The following is a list of commonly used ClinDoc terms, acronyms and icons with descriptions:
Name
Icon
Annotation
(to a diagram)
Description
An Image
icon next to an eDocument indicates that it has
an annotation. Viewing the Annotation Detail window shows a
larger view of an annotated image i.e. marked-up body image.
You can add comments to a structured note or free text
document, however you cannot append flowsheets. You can
view an appended note by viewing the document in the
Document Details window. The word Addendum precedes the
appended note.
Append (Addendum)
Attachment
You can link additional information to certain types of patient
data, e.g. attach a structured note to an allergy or intolerance.
After you have created an attachment, you can view the
attached items, remove and reinstate links to attached items,
and add new attachments.
Care and Assessment
Flowsheet
CAAF
Clinical
ClinDoc
A standardized and structured approach to chronological
documentation of ongoing assessments and care provided to
patients, such as system assessments, fall risk assessments and
ADL assessments, etc.
A component of the EPR used to document and communicate
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Documentation
Clinical Summary
Consult (eDocument)
Electronic Signature
EPR Flowsheet
Free Text note
Health Issues
History & Physical
(eDocument)
H&P
History of Present
Illness
Initial Assessment
HPI
Intelligent Medical
Object
Modify
IMO
IA
information specific to patient diagnosis, assessment, treatment,
care, observations and progress. Also commonly referred to as
an eDocument.
A quick overview of relevant clinical information that physicians,
nurses and allied health can view at a glance. It is a snapshot in
time of key clinical information which will be used to improve
communication relating to patient care.
An electronic comprehensive structured note and/or free text
(general) consult note completed by a care provider.
An electronic method that indicates that a person approves and
has verified the content of an electronic document.
Provides a standardized and structured approach to
chronological documentation of ongoing assessments,
observations and care provided to patients, such as Vital Signs,
system assessments, ADL, etc.
Components of a document that are not structured and can take
any combination of text, numbers, and symbols.
Examples are: Patient’s medical diagnoses, health problems, or
conditions identified by a discipline. The Health Issues Manager
enables you to add and update a patient's health issue. You can
also view the active, inactive, or deleted health issues
associated with a patient.
A comprehensive structured note of a patient’s medical/surgical
history and assessment, completed by a designated care
provider.
A care provider’s initial assessment related to the patients chief
complaint on admission.
A comprehensive structured note completed within a set time
period (as per policy) of a patient’s admission assessment by a
multidisciplinary team of professionals.
A list of diagnoses coding found in the Coding Scheme catalog
search in the Health Issue Manager window.
You can edit a document as required; add new text or update
structured notes, free text documents. The document Has
Been Modified
icon will appear in front of the modified
eDocument. You must have the required security rights to
modify a document.
Problem List
Progress Note
(eDocument)
Structured Note
Tiles
A list of patient problems entered on an eDocument with the
ability to add an assessment and plan. Patient problems are
documented in the H&P (structured notes) to view, review, add
and update according to priority.
A comprehensive or general structured note explaining a
patient’s condition and progress while hospitalized.
A configured document that has a uniform format. It allows the
author to include little or as much information as clinically
relevant.
Patient data appears in a summary view which is subdivided into
sections i.e. tiles. You can customize and save clinical summary
segments containing the patient information that a care provider
works with regularly.
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V. DOCUMENTS
The Documents tab enables you to view and maintain all the free text documents and
structured notes for a patient. You will utilize the Initial Assessment and Nursing
Progress Note the most frequently. Physicians will utilize the history and physical,
consults, and discharge summaries.
The Documents tab includes:
Documents Tab Toolbar: Contains buttons and commands that are specific to the
Documents tab.
Options Panel: Filters the criteria for displaying the documents in the Documents
Grid.
Documents Grid: Displays documents for a selected patient according to the criteria
specified in the Options Panel.
Documents tab
Documents Tab
Toolbar
Options Panel
Documents
Grid
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Entering a Document such as a progress note (on the EPR)
2. Enter Document
1. Select the correct patient before
clicking on the Enter Document
Click on the Enter Document Icon
After clicking on
the Enter
Document icon,
the Document
Entry Worksheet
window opens.
type in what you are looking for, i.e.
“progress note”
Then click on general
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Type your note directly in the open
box
A Structured Note is formatted with a
standardized and structured approach to
clinical documentation. Examples of options
for entering data in a Structured Note
include:
The entry of clinical data and
assessments
The annotation of images
The creation of patient problems
And the entry of data such as Health
Issues and Allergies
Structured note entry creates an eDocument that appears like a paper chart document.
eDocument
Patient Header
eDocument
Name
eDocument Content
Student Exercise Using steps outlined above. Enter a nursing progress note for your
patient #4. Pretend you have completed a dressing change and are documenting this. You
can use a DAR or SOAP format if you would like, but it is not required.
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W. FLOWSHEETS
The Flowsheets chart section allows you to chart, monitor, and review clinical data for
the selected patient. Flowsheets represent the most common type of documents used
to record the observations for a particular period of time.
Currently there are two Flowsheets within the Flowsheet Manager: Care and
Assessment Flowsheet and Vital Signs Flowsheet.
Accessing Flowsheet Manager
There are two ways to access Flowsheet Manager:
Flowsheet Manager Icon
on the EPR Toolbar
OR
Flowsheets tab on the EPR
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Flowsheet Manager Overview
Options Panel
Flowsheets Toolbar
Flowsheets Content
Flowsheet Headers
Observation
Set
Observation Items
W.1 CARE AND ASSESSMENT FLOWSHEET (CAFF)
The Care and Assessment Flowsheet (CAFF) provides a standardized and structured
approach to chronological documentation of on-going assessments and care provided
including:
Systems Assessment (e.g. CVS, Resp)
Risk Assessments (Modified Schmid Falls Risk Assessment and Braden
Assessment)
Care Provided (e.g. ADLs)
Certain Care and Assessment Flowsheet observations and interventions that are
documented on the Initial Assessment (IA) eDocument will flow into a column on the
Care and Assessment Flowsheet once the Initial Assessment eDocument is saved. The
column will reflect the time that the Initial Assessment was saved.
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Your CEF will advise you what sections of the CAFF are required to be documented on in
your patient care area. Not all units utilize every section of the CAFF
Overview of Care and Assessment Flowsheet
Options Panel
Flowsheet Toolbar
Flowsheets Content Area
Flowsheet Headers
Flowsheet Headers in the CAFF
Fall Prevention and
Intervention Care
Plan
Confusion
Assessment
Method (CAM)
Braden Scale for
Predicting Pressure
Sore Risk
Mobility
Assessment
Activities of Daily
Living (ADLs)
Central Nervous
System
Cardiovascular
Nervous System
Respiratory System
Integumentary
System
Gastrointestinal
System
Genitourinary
System
Musculoskeletal
System
Eye Ear Nose
Throat System
Emotional /
Psychological
Mental Status
Within the Flowsheet Headers there are Observation Sets. Within those Observation
Sets are Observation Items that you will chart clinical data against. The following is an
example of some of the Observation Items you will find under the Flowsheet Headers.
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Flowsheet Header
Observation Set
Observation Items
Locked and Unlocked Flowsheet
Two users cannot enter data for the same person at the same time on the same
Flowsheet Time Column.
The first user who accesses the Flowsheet Time Column will be the primary user. This
will “Lock” any other potiential users from entering data into the same Flowsheet Time
Column.
Lock and Unlock Symbol. If the lock is displayed as
open, you may enter data into the Time Column for
the Observation Items. If the lock is closed, you
cannot enter data into the Time Column for
Observation Items as someone else has accessed
the Time Column for the Flowsheet first.
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Entering Patient Information within the Care and Assessment
Flowsheet (CAFF)
Entering Data into the Care and Assessment Flowsheet
At the bedside, the student nurse completes assessments on the patient and enters
them into the Care and Assessment Flowsheet.
NOTE: Prior to entering information into the CAFF, ensure that you have the correct
patient selected within the Electronic Patient Record.
Student Exercise: Add a Time Column to Pt #4’s CAFF by:
Clicking on the Add Time Column Options icon
Time Column.
and selecting Add Single
Click, OK
Time Column is now added to the Flowsheet
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Student Exercise:
1. Select your patient #4 from your patient list.
2.
Click the Flowsheets tab and select the Care
and Assessment Flowsheet
3.
Select Respiratory System by clicking on the +
4. Enter the following respiratory assessment for your client: Airway is patent,
patient is not ventilated, breath quality is regular and deep, air entry is clear
to all lobes, cough is non productive, there is no sputum, client performing
DB&C on own, suctioning not required.
5. Add another singe time column, enter a Cardiovascular System (CVS)
assessment, use your imagination and fill in the fields with a client who had a
completely normal cardiovascular assessment .
6. Go back to the respiratory assessment and delete the data from the cough
cell.
7. Click the Save button on the far right of the Flowsheet Content Area.
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NOTE: You will notice that when you Save the Time Column, italics are removed.
Updating Data in the Care and Assessment Flowsheet after Saving Document
If you make an error in inputting data into a Time Column after you have saved it, you
may go back and correct the data you entered. However, after you make the correction
and click the save button again, you will notice a red in the top corner of the Time
Column Observation Set Cell. This indicates that a correction of a value has been made.
1. Click on the Observation Items you wish to correct. Make your changes to the data for the
Item. 2. Click the Save button on the far right side of the Flowsheet Content Area
W.2 VITAL SIGNS FLOWSHEET
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2. Open a Time Column by:
Clicking on the Add Time Column Options icon
and selecting Add Single Time
Column.
You have options to change the date and or time if
warranted.
Click, OK
Time Column added to Flowsheet
Click within the Observation Item cell you wish to add a value to.
Enter the value into the Observation Item cell.
NOTE: Notice that beside the Vital Signs in brackets (Contains Unsaved Data), this is
to inform you that you have entered data into the cells but have not yet saved this
data.
Click the next Observation Item cell you’re working in.
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Selection window opens
Click on appropriate indicator.
Click, OK
Student exercise: Using the steps outlined above:
Enter your client #4’s Vitals as follows:
Temperature: 37.2 C oral
HR: 64 BPM, regular, obtained via auscultation
Resp Rate: regular 16
BP: 128/76 manual non invasive blood pressure taken from right arm
with patient sitting
Oxygen saturation: 98 % on room air.
X. Clinical Summary
The Clinical Summary tab displays a summary view of a patient's chart in a tiled format.
Patient data appears from chart sections containing one particular type of data Clinical
Summary is a view of relevant information that resides in other parts of the chart and
provides a snapshot in time of key clinical information which will be used in conjunction
with other relevant information to improve communication relating to patient care. The
Clinical Summary in our training database is blank, but you will see much data on
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your actual patients Summary’s. Please Note: This is a good place to go when you are
starting your client research.
Clinical Summary View
Clinical Summary Toolbar
Clinical Summary tab
Date and Time Frame
Y. PATIENT PROBLEMS
Health Issue (HI) Manager is used for the documentation and management of patient
centric information including registration screening, current and historical medical
problems, and visit related information (visit reason/discharge diagnosis). Student
Nurses will not be initializing the HI, but will view it.
Patient Problems include: Visit Reason, Antibiotic Resistant Organism (ARO) Screen,
Advance Health Plan (ACP), Infection Control and Health Care Directive (HCD), Current
Problems, Chronic Problems, Medical History, Surgical Procedures and Family Medical
History.
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Now you are ready to complete your validation exercises (your test), in order to
do this first delete your special list
With your list special list selected, select Delete Current
Icon from the menu options.
List
>>Note: Make sure that you have the list that you want to delete selected first.
It will delete whatever list you have currently displayed.
Click OK in the confirmation window.
Please complete your EPR validation exercises now. You may use the
manual for help if you wish.
When done, shut down
the Eclypsis Gateway (red
button on top right hand
of application toolbar),
Then disconnect from
virtual machine by clicking
on the start button (lower
right hand side of screen),
and then disconnect
Leave your completed validation exercises sheet and worksheet for classroom training in two
separate piles on the instructor’s desk. You are now free to go
IF YOU HAVE COMPLETED THE MODULE INDEPENDENTLY (not in a class) submit to Kim at the Front
Reception area of Helen Glass Centre
Kim will log in once everyone is done and check your exercises
If she has any questions or concerns she will contact you
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