PCD TRAINING MANUAL

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PCD TRAINING MANUAL
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What is PCD??

• Patient Care Documentation
• Computerized nursing documentation
• Developed by Siemens 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.

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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.

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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 SW as a student.

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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

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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.
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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.
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More Navigator Facts
Once a patient is selected different functions
are available.
The patients name and the user ID display at the
top of the screen
Items preceded by a sphere display multiple
options when item is selected
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Vital Signs
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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
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Charting Vital Signs
Click on cancel to exit pathway without
entering data.
To add more vital signs, Click here.
Click update complete to chart
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Revise Vital Signs
Indicates the person Entering the data
Vital signs are grouped in reverse chronological
order.
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Revise Vital Signs
From the vital display, select vs to be revised
Then click on revise.
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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.
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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.
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Intake and OutputIO
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Entering IO
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 the date/ time I O collected
Enter amount of intake or output in mls
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 I0
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Comments
A comment field is provided For each IO
source Click OK when completed
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Intake Output Sources
Select intake or output to add sources
Click Add when desired sources have been selected
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Revise IO
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
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Revise IO

• 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.
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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
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CMST ChecksRestraint Documentation
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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
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Chart Assessments

• Admission/Shift/Focus Assessment

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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.
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Admission Assessment
Selecting Required Assessments automatically
selects 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
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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
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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
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Admission HistoryNutritional Screening
Not required but useful information
Selecting any of these will send a consult to
Nutrition Services
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Admission HistoryChaplain Referral
Selecting chaplain referral will generate consult
These fields are mandatory. Cannot move forward
until completed
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Admission HistoryContinuum of Care
Anticipated discharge placement
Selecting any of these will generate a referral
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Admission HistoryAdvance Directives
Executed Advance Directives is a required field
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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.
RNs select continue to move on to physical
assessment.
LVNs may only select Update Pending Update
Complete will be grayed out
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AssessmentWithin Defined Limits (WDL)
WDL All indicates your assessment meets the
defined limits Select except for to document
exceptions to WDL.
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Assessment Cardiovascular
Most selections can be entered via the point and
click method using the radio buttons, Checkboxes
and free-text data entry fields
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AssessmentEdema
Click the Grade button for definitions
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AssessmentBraden Scale
Braden scale must be assessed every 24 hours
Document any skin abnormality from this screen
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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 care policy
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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.
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Assessment Storing Data
Assessments that were visited are underlined
Select update/complete or update/pending to save
entered data
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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

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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
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View Assessments
Click to view assessment, select assessment and
click view.
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View Assessment
This is how data displays when View Assessments
selected
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Change/Delete Assessment
Select the assessment to be changed or deleted,
then click the appropriate button for that
function.
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Change Assessment
Only change your own assessments
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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.

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

• Use Delete when you have charted on the wrong
  patient.
• Delete only your own assessments

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Copy Assessment
Select copy an existing assessment Select
assessment to be copied. Click copy.
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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.

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Complete Pending Assessment
Select complete assessment, choose assessment in
pending status (P), and click complete.
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Discharge Assessment
Enter date/time the patient left the unit. Not
the time of the discharge order
Click continue to move to next screen
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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
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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 eventsfalls,
codes, etc.-- or Nursing Diagnoses not addressed
in assessment pathways
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Take ever opportunity to learn.

• Be safe out there!