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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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 • Identify the appropriate times to document an assessment
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.
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.
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.
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.
We can now see our Interventions listed in alphabetical order from A to Z on this screen.
To change the screen back to being ordered according to frequency, all you have to do is click on the Next Scheduled Column and the list will rearrange.
Interventions are expected to be performed at the times that appear in the Next Scheduled column, but you may document additional episodes of care at any time.
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.
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.
To document our admission vital signs, we will first click on the correct intervention in our worklist so that it becomes highlighted light blue, as seen here.
Next we will click on Document to open the screen where we can record our vital signs.
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.
This is the vital signs assessment screen. The first question asks you to enter the patient’s temperature in degrees Celsius. To the right of the pink/green answer box we can see the range of temperatures that are considered normal for an adult patient.
Notice the pink and green colors in the answer box. Any temperature we enter that is considered within the normal range will appear in the green section.
Any high temperature indicating fever will appear in the pink area to the right.
Now we are ready to document our patient’s temperature. To do so, we have to click inside the pink and green answer box.
This will open keypad where we can enter out patient’s temperature. You can see the normal temperature range for our patient listed at the top of the keypad.
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.
We will now enter a temperature of 39 degrees for our patient. We can do this by clicking on the buttons on the keypad with our mouse, or by typing them on the keyboard. After we type in the temperature, we will click on the OK button on our keypad.
Notice that the 39 displays in the pink area to the right, indicating an elevated temperature. You can see that the screen automatically converted the Celsius reading into Fahrenheit for you.
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.
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.
Carotid (Neck) Apical (Heart) Brachial (Upper Arm) Radial (Lower Arm) Femoral (Groin) Ulnar (Wrist) Popliteal (Knee) Dorsalis Pedis Tibial
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.
In order to be able to document our second pulse location, we need to insert a second pulse occurrence for our patient. To do that, have to click on the words Insert Occurrence at the bottom of the screen.
Notice that when we clicked on this button, it added a second blank area for us to document our second pulse for our patient – a left brachial pulse of 67 taken via palpation. We will document this second pulse information on our screen now. Pulse #1 Pulse #2
We will now document our patient’s blood pressure. Notice there are two separate documentation boxes to record the upper (systolic) number and lower (diastolic) number. Our patient has a BP of 131/78, which we will fill in now.
We will finish our blood pressure documentation by recording that our patient’s BP was taken in his left arm with an automatic cuff while he was lying down on his back (supine).
The next section we need to document is the patient’s respiratory rate. Our patient has a respiratory rate of 16 breaths per minute, which we will record now.
Notice that we have reached the bottom of our documentation screen. To advance to the rest of the vital signs documentation, we will use the scroll bar on the right side of the screen.
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.
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
Our patient is currently on room air, which will document now.
We have skipped the next two questions, Oxygen Flow Rate and FiO2, since they apply to patients who are on oxygen and our patient is not. Our patient has a pulse ox reading of 97%, which we will enter now. Do Not Apply
Now that we are finished documenting our vital signs, we need to save our documentation. We will now click on Save.
Once we have filed our admission vital signs, we are returned to our intervention worklist. Notice that the History column on this screen displays 0 min, indicating we just finished our documentation.
Now that the admission vital signs are complete, it is up to the nurse taking care of the patient to complete the intervention off the patient list. Once the nurse changes the status from active to complete, you will no longer see the intervention on your worklist.
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.
Now we can click on the word Document at the bottom of the screen to begin our documentation.
Clicking on the Document button will open up the date/time keypad. Our documentation is within an hour of the time we performed the intervention, so we will click on OK at the bottom of this window.
You will then have the opportunity to select which intervention you wish to document on first. We will click on Height & Weight – Adult to open that documentation.
We have documented the Height & weight answers for you. To advance to the next piece of your documentation, we will click on the Go to button.
This will open the Go to window where we can see the intervention we just completed in magenta, indicating we have documented it already. Now we will click on Abdominal Girth to advance to this documentation.
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.
We are now returned to our intervention worklist. We will see a purple line of text on the screen underneath the two interventions we just documented. This is our reminder that we still need to save the documentation. We will click on Save now.
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.
Once again we see the date/time window open. These interventions were performed within the hour, so we will click on the OK button.