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Documenting Interventions. PCS Lesson 3. Objectives. Identify the process by which you will enter baseline and routine vial signs Demonstrate how to enter information using the keypad Describe how to read and use the colored indicator Identify the features if the document spreadsheet

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Objectives

  • Identify the process by which you will enter baseline and routine vial signs

  • Demonstrate how to enter information using the keypad

  • Describe how to read and use the colored indicator

  • Identify the features if the document spreadsheet

  • Identify the appropriate times to document an assessment


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  • This lesson will cover how to document interventions on your patients. We will assume a patient just arrived to your unit and we need to enter the initial admission vital signs and then follow up with routine documentation of other interventions. We will also learn how to document a patient’s intake and output. We have already added the new patient to our status board and chosen a Standard of Care for her. Now we will begin our documentation.


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  • Our patient is already highlighted on our patient status board because we have clicked on her name. It is very important to remember to click on the correct patient before you begin your documentation. Now that the correct patient is highlighted, we will click on the Interventions button on the right side of the screen to start our documentation.


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  • The intervention worklist displays the list of interventions that need to be documented. Some of these interventions were added through the Standard of Care and some will flow over to this screen from Order Entry. The items on the intervention worklist are are listed in order according to frequency. Any overdue interventions will appear at the top of the list in the Next Scheduled column with a pink background.


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  • We can also sort out Intervention list alphabetically. This is often helpful if we have several interventions on our worklist for a patient. To alphabetize your Intervention worklist, you will click on the column header where it says Intervention. Let’s see what this looks like.


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  • We have just collected the admission vital signs for our patient and will document them using the Vital Signs: Adult Intervention. Notice we have two of these interventions on our worklist. The one we want to use to document admission vital signs is the one with the frequency of On Admission. We will only document on this intervention once, then we will use the other vital signs intervention with a frequency of q4h for the rest of our documentation.


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  • You have one hour to get your documentation into Meditech. For example, if you do a set of vital signs at 0800, you have until 0900 to enter them into the computer. If you are after this time, you will have to back time your documentation. We will learn how to retrospectively document in another lesson. The best thing to do is enter your documentation into the computer as soon as you provide the care. This will prevent you from taking a longer time to get your documentation finished.


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  • After you click on Document, you will have to select the date and time you performed the intervention. If your documentation is within an hour of the time you actually performed the intervention, you can simply click on OK at the bottom of this window. Otherwise, the date and time will need to be changed to reflect the accurate time the intervention was performed. We will click on OK now.


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  • The keypad also has a certain range of temperature values that it will accept called the Input range. If you try to enter a temperature above or below this set of values, it will give you an out of range message to let you know you probably have incorrectly entered your temperature for your patient.


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  • The next question on this screen is the Source of the temperature, meaning the method by which the temperature was obtained. Our patient’s temperature was taken orally, which we will record now by clicking anywhere on the word Oral or in the parentheses next to the word Oral.


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  • We have now finished documenting our temperature and are ready to move onto the next section of the assessment – Pulse. A pulse is an example of something Meditech calls an occurrence. An occurrence is something that can be documented in several different locations. For example, you can take a pulse in the Right Radial section of the arm, or a left Pedal pulse on the foot. We can add as many occurrences as we need to in order to document correctly on our patient. Let’s take a look at some of these possible locations for pulse.


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Carotid (Neck) are ready to move onto the next section of the assessment – Pulse. A pulse is an example of something Meditech calls an occurrence. An occurrence is something that can be documented in several different locations. For example, you can take a pulse in the Right Radial section of the arm, or a left Pedal pulse on the foot. We can add as many occurrences as we need to in order to document correctly on our patient. Let’s take a look at some of these possible locations for pulse.

Apical (Heart)

Brachial (Upper Arm)

Radial (Lower Arm)

Femoral (Groin)

Ulnar (Wrist)

Popliteal (Knee)

Dorsalis Pedis

Tibial


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  • We took two pulses on our patient – one for the right radial artery, and one for the left brachial artery. First we will document the right radial pulse of 88 taken electronically by clicking on the appropriate sections of the assessment, as seen on this screen.


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Pulse #1

Pulse #2


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  • The next question refers to the patient's oxygen delivery method. It is very important to document whether the patient is on room air or oxygen if you are documenting a pulse ox reading for the patient. This is a required question and you will not be able to Save until you have documented this answer.


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  • You may also notice the answer options for this question have squares to the left of them. Any time a question has a square check box, it means you can select more than one answer for that question. All of your previous answer choices had circles that you could click in to select them. A circle means only one answer choice can be selected for that question.

Circles

Squares



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Do Not Apply


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  • Let’s take a look at how we would document two interventions back to back, without having to go back to the intervention worklist between them. The two interventions we wish to document at the same time are Height & Weight and Abdominal Girth. To document more than one intervention at a time, we must first click in the empty boxes to the left of the intervention names to create check marks, as shown on the screen here.


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  • We have filled in our patient’s abdominal girth. Notice the world Save in the lower right-hand corner is grayed out. When we document on two interventions in a row, we will use the Return button to take us back to our Intervention worklist, where we will be able to save or documentation.


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  • Let’s assume some time has passed and we want to document our patient’s Meal Intake and Intake & Output. We will document both of these at the same time by placing a check mark in the column the left of the intervention name, as shown on this screen, and then clicking on the Document button.


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  • This is the Meal Intake screen. Notice the answer options for the Current Diet question have square check boxes. This means we can select more than one diet for our patient, if appropriate. Here we have selected that our patient is on a 1600 Calorie ADA, low salt diet and that he ate 75% of his lunch tray.


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  • The next question is about our patient’s oral intake with lunch. Note the blue text in the answer section for this question. It tells us to document a patient’s oral intake on this screen OR the Intake and Output intervention. It is very important we only document this amount in one place or the other, NOT on BOTH interventions. Otherwise, it will appear in the EMR that our patient had twice as much to drink as he really did.


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  • We are now viewing the Intake and Output screen. Intake and Output should be documented as it is collected. In other words, document your patient’s Intake and Output as you go, not just at the end of the shift. Remember, we will not document our patient’s oral fluids here, as we already documented them on our Meal Assessment Intervention.


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  • The screen is broken up into Intake and Output sections. We will only document what is appropriate for our patient. Here we have documented urine and emesis output for our patient. Notice that the screen will total our answers for us as we go.


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  • Whenever you have repetitive documentation on your patient, it can be helpful to have the screen organized in a spreadsheet view. You may find it easier to use Document spreadsheet for your routine documentation. It also allows you to see previous documentation on the screen while you are documenting.


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  • Let’s use vital signs as an example. Instead of double clicking on the intervention name or clicking on the word document to begin our vital signs documentation, we will instead click on vital signs once to highlight the intervention (as we see now on our screen), and then click on the Document Spreadsheet button.


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  • When we are documenting on the spreadsheet, we will move down the new column we just added by clicking in the boxes one at a time. The first row on the spreadsheet is the temperature (Celsius). To enter our information into the spreadsheet, we will click directly in the empty box, as highlighted here.


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  • The temperature is now filled in on the spreadsheet for you. Just like on our other documentation screen, Meditech has converted the temperature to Fahrenheit for you. The next question asks about the Source of the temperature. We will click in the empty box in our column to answer this.


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  • When you click in an empty box in the column, the answer options will appear. All we have to do is select our answers by clicking in the boxes next to the appropriate options on the screen. Here we have selected the Oral temperature source. Now we will click on the OK button to deposit our data onto the spreadsheet.


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  • Let’s take a look at our options along the bottom of our screen while in the spreadsheet view. Notice we can insert or delete occurrences from this screen, just like we can from the regular document view. To insert or discontinue an occurrence, we would click in the side or location row for our vital signs, and then click on the appropriate occurrence button.


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  • Now we are ready to Save our documentation that we have completed on this screen. We can tell we still have un-saved data because the upper left column header is green and has the Data to File message showing. Another way to tell we have not saved our documentation is that the text in our column header is purple. we will click on Save to save this documentation now.


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Great Job!! click on the Red X to log all the way out of Meditech.

  • You still need to learn how to edit your documentation, undo documentation mistakenly entered on the wrong patient, and how to retrospectively document.

  • All of these skills will be learned in the Document Edit lesson.

  • Remember if you need help, go the the Nursing webpage on the Infoweb and click on Meditech Help Link.


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