PCD TRAINING MANUAL Licensed Staff

What is PCD?? “Patient Care Documentation” Computerized nursing documentation developed by Siemens’ company On all hospital units except for ICU, ED, Labor & Delivery, Post partum, NICU. Adult ICU & PICU use the admission history section only.

System Sign-on The User ID & password are your legal signature. Always log off when the transaction is complete. Never allow anyone else to use your password. Contact the Help Desk ( ) or log into Passport to change your password*. A record is kept of all transactions. Your Sign-on is last three characters of your mainframe sign-on; example: 123ABC Your Password is your mainframe password: random letters & numbers assigned by IS.*

Nurse Station Census The unit census defaults to where the user signs on. Net Access navigator bar. Can be used to locate patients by name or MRN inquiry.

Nurse Station Census Patients are listed in Room/Bed order, Name highlighted in blue and underlined Click once on the patient name to select patient. View census of another unit by selecting Unit Census from the Navigator Bar and choosing the unit

More Navigator Facts Once a patient is selected, different functions are available. The patient’s name and the user ID display at the top of the screen Items preceded by a sphere display multiple options when item is selected

Vital Signs

Charting Vital Signs Defaults to current time, may change date and time. May chart past 48 hours. Can NOT chart in the future Use spin buttons or free text the values Move from field to field using mouse or tab key These are now mandatory

Charting Vital Signs To add more vital signs, Click here. Click update complete to chart This is your “save” button Click on cancel to exit pathway without entering data. Three places available for orthostatic B/P’s Now mandatory

Revise Vital Signs Indicates the person Entering the data *****Only Licensed Staff can revise vital signs: RN anyone LVN only their own CNA cannot at all

Revise Vital Signs From the vital display, select data to be revised Then click on revise. Only licensed staff can revise: RN revises anyone LVN revises only their own CNA cannot revise at all

Revise/Delete Vital Signs Choose a radio button: 1. Revise result to change incorrect data on correct patient. 2. Mark as error to delete data entered on wrong patient. Once chosen, fields are enabled to allow revision. Make changes and Click OK. When using Mark as Error, A reason must be entered. Using skip button allows user to leave screen without making changes.

Display Vital Signs This displays the last 5 sets of VS. To see all since admission, click all. Revised VS will display this way showing Incorrect data as well as corrected data. Vital Signs mark as an error display this way

Intake and Output I&O

Entering I&O Enter the date/ time I & O collected Enter amount of intake or output in mls Select box in front of source to delete a source that is no longer needed. The box will be grayed out if data has been entered in the last 24 hours (it cannot be deleted). Excluded sources are not included in the I/O totals. An “X” will display in the excluded column. IE Stool Count Click OK to store data Select Add Comments to Enter additional data about I&0 Approximations will not be added to totals. They will appear as “+”.

Comments A comment field is provided For each I&O source Click OK when completed

Intake & Output Sources Select intake or output to add sources Click Add when desired sources have been selected

Revise I&O Only licensed staff can revise: RN revises anyones LVN only their own CNA cannot revise at all Select the item(s) to be revised Click revise Shows the date/time interval for the displayed data. T indicates comment

Revise I&O Choose radio button: 1.Revise result to change incorrect data on correct patient. 2.Mark as error to delete data entered on wrong patient. Once chosen, fields are enabled to allow revision. Make changes and click OK When using Mark as Error, A reason must be entered. Using skip button allows user To leave screen without making changes.

Display I & O Shift times in columns link to additional information “T” indicates a comment was added. Sources marked excluded will not show in the total

Chart Assessments Admission/Shift/Focus/Discharge Assessments

Create New Assessment Select assessment type and click begin Date and time should reflect actual date and time assessment was performed. ******Documentation choices depend on job title.

Admission Assessment From this screen document Admission History, Admission assessment, ad other needed assessments, ie, pain/ comfort or restraints. Selecting ‘Required Assessments’ automatically selects the Admission History, Body Systems, Fall Risk, Pneumonia/Flu, Sepsis Screening and Education. Others may be selected as needed. Each system displays in the order they appear on this screen. Select chart detail to continue *****Assessments can only have one time assigned to that assessment. If the LVN does the adm hx, RN who completes the admission must time her assessment at least 1 minute later.

Admission History Opt Out is a mandatory field. Answering “yes” only indicates that you have offered the patient the option not whether they want to opt out or not. Arrival Date/Time must be entered Ask the patient each question in the admission history. Only applicable data is actually entered into the system. ‘…’ indicates additional screens will appear if the item is selected Adult ICU, PICU and CCH only do Admission History,

Admission History Personal Belongings You must describe clothing, cash, jewelry, other Location is mandatory if the field is selected Use these buttons to move between screens

Admission History Nutritional Screening Selecting any of these will send a consult to Nutrition Services Not required but useful information

Admission History Chaplain Referral Selecting “chaplain referral” will generate automatic consult These fields are mandatory. Cannot move forward until completed

Admission History Continuum of Care Anticipated discharge placement Selecting any of these will generate a referral

Admission History Advance Directives Executed Advanced Directives is a required field

Admission History Past Medical/Surgical History LVNs may only select “Update Pending” Update Complete will be grayed out Enter date of vaccination if known, You can check ‘Immunization History” in Navigator bar for immunization date status if unknown. This is S&W info only. This screen allows you to collect data regarding existing conditions that may affect the care during this admission. RN’s – select continue to move on to physical assessment.

Pneumococcal Screen Screens are age based: Either > 65 yrs of age or 18 – 64 yrs of age yr old must have a chronic illness to qualify. Chronic illness box lists example diagnosis Patients in SWMH ICU are not screened for vaccinations This question refers to this group or questions only

Flu Screen Verify that months are within flu season Verify if flu vaccine already given this flu season. Refer to immunization history in navigator bar. Make sure you update/ pend before opening immunization history as it will kick you out and will lose everything you just entered.

H1N1 Screen H1N1 to be given until further notice from Administration Patient must: 1. Review H1N1 protocol 2. Meet protocol 3. Consent to vaccine If any of these do not occur, patient does not receive vaccine

Assessment Within Defined Limits (WDL) “WDL All” indicates your assessment meets the defined limits Select “except for” to document exceptions to WDL.

Assessment Cardiovascular Most selections can be entered via the point and click method using the radio buttons, Checkboxes and free-text data entry fields Remember any choice with “…”, additional screens will need to be completed

Assessment Edema Click the “Grade” button for definitions

Assessment Braden Scale Braden scale must be assessed every shift Document any skin abnormality on this screen

Braden Scale Click here to access skin care policy Select either tab or button Select appropriate descriptor or free text number in box Click “Close” or “Continue” to see Braden total score

Assessment Fall Risk You must select either “no fall risk” or one or more of the risk factors listed to proceed.

Fall Risk Interventions Screen Standard precautions always necessary for a fall risk patient. Then, choose any other precautions done to protect patient

Initial Restraint Documentation & Every 2 hour CMST Checks

Initial Restraint Assessment Restraint assessment must be made prior to applying restraints. Document all actions taken prior to application of restraints. This is usually a “focus “note Family and patient must be informed of reason for restraint usage

Restraint Assessment Document all alternatives tried and responses to those

Restraint Assessment Initial CMST (Circulation, Motion, Sensation, Temp) check RN must assess for continuation of restraints or not

Every 2 hour CMST Checks Document Restraint data here Change date/ time as needed to reflect required q 2 hour restraint documentation. Items clicked yes require description Document interventions every 2 hours and add comments as needed Click update complete to store data

Sepsis Screening Shift and Focus This is an example of a patient who is septic but not in severe sepsis or in shock. This screen walks you through the process of identifying a patient who is either: 1.septic (has an infection UTI, Pneumonia, wound infection) 2.In severe sepsis 3.In septic shock This is done q shift on all units. If a patient’s status changes, can be a focus note. This identifies that the patient has more than 2 SIRS and a known or suspected infection. The patient has not had a serum lactate greater than 4 or organ failure

Positive Sepsis Screen This screen has identified a patient who has gone from severe sepsis to shock. 1.The patient had 2 or more SIRS with a suspected or known infection 2.A lactate acid or 4 or greater within the last 24 hours 3.Patient has not had response to fluid challenge to increase B/P 4.Patient has one or more organ failures. Identification of Severe Sepsis or Septic Shock will trigger the pop up box to notify PCP and call a Dr. Rapid. Make comments in the comment box as to what was done in regards to this patients positive screen.

Assessment Storing Data Select update/complete or update/pending to save entered data Assessments that were visited are underlined. Last chance to go back and address any initial assessment you may have missed.

Shift/Focus Assessments Admission History not an option on this screen Required assessments include body systems, fall risk and education Other options, ie, Peripheral IV, Pain/Comfort, etc. may be added as appropriate All other steps are the same as the admission assessment See next slide

Shift/Focus Assessments If Shift or Focus Assessment is selected this screen will appear. Admission History is not an option. ‘Required Assessments’ automatically selects all the Body Systems, Fall Risk, and Education. Others may be selected as needed. Each system displays in the order they appear on this screen. Select chart detail to continue

View Assessments Click to view assessment, select assessment, and click view.

View Assessment This is how data displays when “View Assessments” is selected

Change/Delete Assessment Select Change/Delete Assessment, the assessment to be changed or deleted, then click the appropriate button for that function.

Change Assessment Only change your own assessments

Guidelines for Change Assessment Use Change when you need to modify an existing assessment that you have created. This will not create a new assessment or change the date and time of the original assessment.

Delete Assessment This is the final screen before you delete an assessment Only delete your own assessments.

Guidelines for Delete Assessment Use Delete when you have charted on the wrong patient. Delete only your own assessments

Complete Pending Assessment Select “Complete Assessment”, choose assessment in pending status (P), then click complete.

Discharge Assessment Enter date/time the patient left the unit. Not the time of the discharge order Click continue to move to next screen

Discharge Assessment This question asks if immunization status was assessed. Indicates if administration of vaccine occurred. Document discharge education, patient response, and pain status at time of discharge

Patient Notes Patient Notes is the opportunity to include a narrative note referring to patient care issues not addressed by any assessment pathway. Ex. Response to treatment, untoward events—falls, codes, etc.-- or Nursing Diagnoses not addressed in assessment pathways