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PCD TRAINING MANUAL. What is PCD??. “Patient Care Documentation” Computerized nursing documentation Developed by Siemen’s Company Used on all hospital units except for the ED, Labor & Delivery, Post partum, NICU, and PICU.

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What is pcd
What is PCD??

  • “Patient Care Documentation”

  • Computerized nursing documentation

  • Developed by Siemen’s Company

  • Used on all hospital units except for the ED, Labor & Delivery, Post partum, NICU, and PICU.

  • Limited use in the Adult ICU - use the admission history section only.


System sign on
System Sign-on

  • The User ID & password is your legal signature.

  • Contact the Help Desk (4-2501) if you want to change your password.

  • Never allow anyone else to use your password.

  • Always log off when the transaction is complete.

  • A record is kept of all transactions.


System sign on1
System Sign-on

  • User ID and Password will be issued to you by your faculty.

  • All student IDs will begin with NST. Use only while you are at S&W as a student.


Security
Security

Students who are also employees of

Scott & White

  • If you are a student and an employee, you will have a User ID and password for each role.

  • While you are at Scott & White as a student, use the User ID that begins with NST.

  • Do not use this ID when you are at Scott & White as an employee.

  • While you are at Scott & White as an employee, use the User ID that was provided through Human Resources. Do not use this ID when you are at Scott & White as a student.

    Accessing information using the incorrect User ID, is grounds for termination of employment, and clinical privileges


Nurse station census
Nurse Station Census

Net Access navigator bar.

Can be used to locate patients

by name or MRN inquiry.

The unit census defaults to where the user signs on.


Nurse station census1
Nurse Station Census

View census of another unit by selecting Unit Census

from the Navigator Bar and choosing the unit

Patients are listed in Room/Bed order,

Name highlighted in blue and underlined

Click once on the patient name to select patient.


More navigator facts
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



Charting vital signs
Charting Vital Signs

Defaults to current time,

may change date and time.

Can NOT chart in the future

Use spin buttons

or type In the values

Move from field to field using mouse or tab key


Charting vital signs1
Charting Vital Signs

Click on cancel to

exit pathway without

entering data.

To add more vital signs,

Click here.

Click update complete to chart


Revise vital signs
Revise Vital Signs

Indicates the person

Entering the data

Vital signs are grouped in reverse chronological order.


Revise vital signs1
Revise Vital Signs

From the vital display, select vs to be revised

Then click on revise.


Revise delete vital signs
Revise/Delete Vital Signs

  • Choose radio button:

  • Revise result to change incorrect data on correct patient.

  • 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
Display Vital Signs

Revised VS will display this way

Vital Signs mark as an error display this way

This displays the last 5 sets of VS. To see all since admission, click all.



Entering i o
Entering I&O

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

Enter amount of intake or output in mls

Enter the date/ time I & O collected

Exclude sources are not included in the I/O totals.

An “X” will display in the Excld column. IE Stool Count

Click OK to store data

Select Add Comments to

Enter additional data about I&0


Comments
Comments

A comment field is provided

For each I&O source

Click OK when completed


Intake output sources
Intake & Output Sources

Select intake or output to add sources

Click Add when desired sources have been selected


Revise i o
Revise I&O

Only licensed staff can revise

Shows the date/time interval

for the displayed data.

Select the item(s) to be revised

Click revise

T indicates comment


Revise i o1
Revise I&O

  • Choose radio button:

  • Revise result to change incorrect data on correct patient.

  • 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
Display I & O

Shift times in columns link to

additional information

T indicates a comment was added

Sources marked exclude will not show in the total


Cmst checks restraint documentation

CMST ChecksRestraint Documentation


Cmst checks
CMST Checks

Change date/ time as needed to reflect

required q 2 hour restraint documentation.

Document Restraint data here

Items click yes require description

Document interventions every 2 hours and add comments as needed

Click update complete to store data


Chart assessments

Chart Assessments

Admission/Shift/Focus Assessment


Create new assessment
Create New Assessment

Date and time should reflect

actual date and time assessment

was performed.

Select assessment type and click begin

LVNs do not have discharge assessment listed.


Admission assessment
Admission Assessment

Selecting ‘Required Assessments’ automaticallyselects all the Admission History, Body Systems, Fall Risk, and Education. Others may be selected as needed. Each system displays in the order they appear on this screen.

Last chance to modify date and time.

From this screen document Admission History,

Admission assessment, and other

needed assessments, ie, pain/ comfort or restraints.

Select chart detail to continue


Admission history
Admission History

Ask the patient each question in the admission history. Only applicable data is actually entered into the system.

Arrival Date/Time must be entered

Opt Out is a mandatory field

‘…’ indicates additional screens

will appear if the item is selected


Admission history personal belongings
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
Admission HistoryNutritional Screening

Not required but useful information

Selecting any of these

will send a consult to

Nutrition Services


Admission history chaplain referral
Admission HistoryChaplain Referral

Selecting chaplain referral will generate consult

These fields are mandatory.

Cannot move forward

until completed


Admission history continuum of care
Admission HistoryContinuum of Care

Anticipated discharge placement

Selecting any of these will generate a referral


Admission history advance directives
Admission HistoryAdvance Directives

Executed Advance Directives is a required field


Admission history past medical surgical history
Admission HistoryPast Medical/Surgical History

This screen allows you to collect data regarding existing conditions that may affect the care during this admission.

Be sure to assess immunization status on admission

Click on Pneumo/Inf to access the Admission Assessment

Hospital Order form and immunization information.

Enter date of vaccination if known,

You can check DWP for immunization date status if unknown.

RN’s – select continue to move on to physical assessment.

LVNs may only select Update Pending

Update Complete will be grayed out


Assessment within defined limits wdl
AssessmentWithin Defined Limits (WDL)

“WDL All” indicates your assessment meets the defined limits

Select “except for” to document exceptions to WDL.


Assessment cardiovascular
Assessment Cardiovascular

Most selections can be entered via the point and click method using the radio buttons,

Checkboxes and free-text data entry fields


Assessment edema
AssessmentEdema

Click the “Grade” button

for definitions


Assessment braden scale
AssessmentBraden Scale

Braden scale must be assessed every 24 hours

Document any skin abnormality from this screen


Braden scale
Braden Scale

Select either tab or button

Select appropriate descriptor or free text number in box

Click “Close” or “Continue”

to see Braden total score

Click here to access skin carepolicy


Assessment fall risk
AssessmentFall Risk

You must select either

“no fall risk” or one or more of the risk factors listed to proceed.

Click here to access fall prevention guidelines.


Assessment storing data
Assessment Storing Data

Assessments that were visited are underlined

Select update/complete or update/pending

to save entered data


Shift focus assessments
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


Shift focus assessments1
Shift/Focus Assessments

If Shift or Focus Assessment is selected this screen will appear. Admission History is not an option. ‘Required Assessments’ automaticallyselects 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
View Assessments

Click to view assessment, select assessment

and click view.


View assessment
View Assessment

This is how data

displays when View Assessments selected


Change delete assessment
Change/Delete Assessment

Select the assessment to be changed

or deleted, then click the appropriate

button for that function.


Change assessment
Change Assessment

Only change your own assessments


Guidelines for change assessment
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
Delete Assessment

This is the final screen before you delete an assessment

Only delete your own assessments.


Guidelines for delete assessment
Guidelines for Delete Assessment

  • Use Delete when you have charted on the wrong patient.

  • Delete only your own assessments


Copy assessment
Copy Assessment

Select copy an existing assessment

Select assessment to be copied.

Click copy.


Guidelines for copy an existing assessment
Guidelines for Copy an Existing Assessment

  • Use Copy when you want to create a new assessment based on a previous assessment of the same type. For example, you need to perform a Respiratory Assessment every four hours. Select ‘Copy an Existing Assessment’. Then, select the assessment you wish to copy. Review the information in the assessment and change those values that are different from the previous assessment. This will create a new assessment but not alter the assessment that was copied.


Complete pending assessment
Complete Pending Assessment

Select complete assessment, choose assessment in pending status (P), and click complete.


Discharge assessment
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 assessment1
Discharge Assessment

Document discharge education, patient response, and pain status at time of discharge

This question asks if immunization status was assessed.

Indicates administration

of vaccine


Patient notes
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



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