Documenting Interventions

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Documenting Interventions

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Documenting Interventions PCS Lesson 3 Identify the process by which you will enter baseline and routine vial signs Demonstrate how to enter information using the ... – PowerPoint PPT presentation

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Title: Documenting Interventions

1
Documenting Interventions

PCS Lesson 3

2
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 patients 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. Lets 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. We
will only document on this intervention once.

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
green, 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
patients 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 low or cold temperature will appear in the
pink area to the left.

Any high temperature indicating fever will
appear in the pink area to the right.

Now we are ready to document our patients
temperature. To do so, we have to click inside
the pink and green answer box.

This will open keypad where we can enter
out patients 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 patients
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.
Lets take a look at some of these possible
locations for pulse.

26
Carotid (Neck)
Apical (Heart)
Brachial (Upper Arm)
Radial (Lower Arm)
Femoral (Groin)
Ulnar (Wrist)
Popliteal (Knee)
Dorsalis Pedis
Tibial
27

We took two pulses on our patient one for
the apical pulse, and one for the left brachial
artery. First we will document the apical pulse
of 88 taken via auscultation 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.

29
Pulse 1
Pulse 2

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.

We will now document our patients 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 patients 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
patients 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.

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
37

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 20 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.

Lets 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 Skin
Risk Assessment. 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 Skin Risk
Assessment to advance to this documentation.

We have filled in our patients Skin Risk
Assessment. 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.

Lets assume some time has passed and we
want to document our patients 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.

This time we will select the Meal Intake
Intervention to document first.

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.

The next question is about our patients
oral intake with lunch. Note the blue text in the
answer section for this question. It tells us to
document a patients 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.

We have documented the rest of this
assessment for you and we are ready take a look
at the Intake and Output screen. We have clicked
on the Go to button and now will click on Intake
and Output.

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

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.

Now that we are finished entering our
patients input and output, we will click on the
Return button.

We have been returned to our Intervention
Worklist. We are finished documenting our
patients Meal Intake and IO values. We will now
Save our documentation.

We have learned how to use the Document
function to record our documentation for our
patient. There is an alternative method of
documenting interventions that you may prefer. It
is called Document Spreadsheet.

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.

Lets 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.

The first screen we will see is our
date/time window. We can back time our
documentation using this keypad if we wanted. For
this example, we will accept the current date and
time on the keypad and click on OK.

This is the document spreadsheet. The same
questions and answers choices are listed here,
but they are in a different format on the screen.

The title of the Intervention and the
frequency will be listed at the top of the
spreadsheet, as seen here.

The questions are listed down the left side
of the screen.

The date and time you entered on the keypad
appears in the column header. The text in this
header is purple, indicating that the data hasnt
been filed yet. This column is where we will
document the most recent set of vitals for our
patient.

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.

This will open a keypad for us to enter the
temperature. We will document a temperature for
our patient of 37.9 and then click the OK button.

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.

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.

We would continue clicking down the column
in all of the appropriate blank boxes to fill in
all of our documentation. The rest of our
patients documentation has been filled in on the
spreadsheet for us.

Nurses will also have the ability to drag
and drop their own documentation from one column
to another column. This information will be
covered in computer class.

Lets 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.

If an occurrence has been discontinued, it
will appear grayed out on the spreadsheet view,
as seen here.

We can also insert new columns or delete
any columns we havent filed yet from this screen
by using the insert/delete columns buttons at the
bottom.

We also see a link at the bottom for
Associated Data, so we can quickly view the past
vital signs documentation from this screen
without having to enter the EMR/Chart to view the
data.

If we want to edit the date and time in our
column header, we can click on the header so it
is highlighted and then click on Edit options and
select Edit date/time from the edit menu.

The view button will allow us to view any
attached protocol, text, or documentation history
for the intervention.

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.

79
We have the option to Save the data and
return to the Intervention Worklist view or save
the data and keep working from the spreadsheet.
We will click on Save and return to Worklist now.

80

Time has passed and our shift is almost
over. By the end of your shift, the Intervention
worklist should be up-to-date with no overdue
interventions.

At the end of our shift, we must remember
to remove our patients from our Status board. To
do this, we will click on the Status Board button
on the right side menu of our screen.

Now we are on our status board. To remove a
patient from our list, we must first click in the
empty box to the left of the patients name, as
seen here.

The next step is to click on the Remove
From List button at the bottom of the screen.

Now our patient has been removed from our
list, and we will log all the way out of Meditech
by clicking on the X in the upper right hand
corner or the Exit PCS button.

We are now back at our desktop. From here,
we will click on the X to log all the way out of
Meditech.

86
Great Job!!

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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