Paragon Training Nursing Students. Logging In At Seton Medical Center we have Single Sign On which...

Paragon TrainingNursing Students

Logging In At Seton Medical Center we have Single Sign

On which allows you to swipe your badge for login.

Swipe your badge over the reader

The Unlock Workstation Window Opens; enter your passwordAnd click OK

Logging In (cont)

Double Click on the Paragon Shortcut on the computer’s Desktop

The Paragon Applications will open. Double click on the Clinical Carestation

Clinical Care Station (CCS)

When you log into CCS the Splash Screen Opens. To access your patients click on the icon in the center of the screen.

In CareGlance look to ensure you defaulted to the correct Nursing Station. If not, click on the drop down arrow for the Nursing Station and pick the correct Unit you are working on.

CCS (cont)

Assigning your patients

Click in the “Assign” Box next to your 1st “assigned” Patient

The “Self Assignment – Shift Selection” Box will open1. Choose your shift from the drop down arrow

2. Click the “Assign…” box so that when you click the other patient’s assigned to you, you don’t have to complete this box again

3. Then Click the OK button and finish assigning the rest of your patients to yourself.

CCS (cont)

Assigning your patients After assigning yourself your patients click the

“Assigned Patients” box (next to the Nursing Station Field.

Click the “Retrieve” Button (think of this as your “refresh” button)

“Bubbles”

All patients have “bubbles” to the right of their names w/ initials above them. Here are a few you will be ac

AA – Admission Assessment (this one is done by the staff RN, but if it is GREEN then it is clear

that an Admission Assessment has been completed by an the staff RN) FS – Flow Sheet RX – Medication Administration NR – New Results Doc – Physician Progress Notes (if they do electronically)

There is a “legend” icon located in the Secondary Tool Bar that can be used to assist you w/ what the color scheme in the bubbles indicate.

CCS (cont)

Patient Profile

The Patient Profile supplies information on patient’s Home Medications, Allergies, Admission Height & Weight, etc.

To Access Highlight the patient you wish to view and click the Patient Profile Icon in the Primary Tool Bar .

CCS (cont)

Patient Profile

To see the Admission Height & Weight (and some additional

information) Click on the down arrow in the Patient Banner

To close this screen simply click the up arrow at the bottom of the screen

CCS (cont)

Patient Profile Another important icon located in the Patient Profile is the Patient History

Icon. Single Click the icon for the Visit History Window to Open

When the Visit History window opens Single click on a visit(at the top of the screen)

To review diagnostic tests for that visit on bottom half of screen.

Double Click on a visit (at the top of the screen)

To Open the Patient’s Medical Record to view H&Ps, and other documentation

HPF (Horizon Patient Folder)(The patient’s legal record)

When HPF Opens there is a one time set-up that will have to be completed before any documentation can be seen.

Click: File Preferences Personal Record View

Personal Record View: Click the Add All button to move all “Documents Not in View to the right “Documents in View” then Click OK

Exit HPF through the Door

Daily Assessments

This Assessment Type is where you document your shift baseline head to toe assessment, your hourly rounding (on the Peep Tab), your pain assessments, IV assessments, etc.

Your instructor will let you know how often she expects documentation in these areas.

Daily Assessment (con’t.)

Click on the “Change Unit Type” Icon in the primary tool bar. Select the Unit Type of LHP-MedSurg

Click on the “Perform Assessment” Icon and choose the “Daily” Assessment

The Daily Assessment will open to reveal these categories (Tabs)

Components of the Daily Assessment The Assessment is made up of “Tabs” or

“Categories”. Within those Tabs are Group Boxes

Within the Group Boxes are Finding Codes Together these components make up your

documentation. A Head-to-Toe Assessment is completed on the

tabs that are all upper-case:


In the Daily Assessment you do have a way to add extra information during your assessment. This can be done 2 ways 1st Way: Create a “Group Note” which allows 255

characters. Simply right click in the group boxes header and click on “Group note”

The blank Group Note Screen will open and you can type up to 255 characters.


The little yellow piece of paper will show in the Group Notes Header

In the Daily Assessment you do have a way to add extra information during your assessment. This can be done 2 ways 2nd way: Create a “Category Note” which allows

255 characters. Simply right click anywhere in the Gray portion of the screen click on “Category Note”

The blank Category Note Screen will open and you can type up to 255 characters.


The little yellow piece of paper will show on the Category Tab

System Assessments are all designed in the same format. All “normal” findings are at the top of the page w/ all “abnormal” findings below (see SKIN tab)


Normal

Abnormal

SMCHH uses the Hendrich II Fall Risk Model. This model has 2 components (Risk Factor & Get-up-and-Go Test) that are added together for a score. If the score is equal to or greater than 5 the patient is considered High Risk for Falls and Fall Precaution Bundle is put in place.


Hendrich II Fall Risk Model

SMCHH uses the McKesson Defined Pain Assessment Screen. This is embedded into the Daily Assessment

Click on the Pain Assessment button Click on the New button at the bottom

of the window to open a “New” Pain Assessment

Click within the fields for the drop down choices.

If this is a pre-intervention assessment click the pre-intervention assessment option and be sure to re-evaluate your patient after intervention. Upon re-eval, click the post-intervention assessment option.

Daily Assessment (con’t.)McKesson Pain Assessment

“Rounding” at SMCHH is done on the Peep and/or Intervention tabs

You only document on the tabs that you need.

To close an assessment ALWAYS “yellow arrow” out.

You will be asked “do you wish to close this assessment? Click YES if you have completed the assessment of NO if you wish to come back and finish the assessment later


ALL Teaching documentation is completed under the “Follow-Up” Assessment Type

Click on the “Perform Assessment” Icon

Select the Follow-Up Assessment

The Follow-Up Assessment will open. There are 3 tabs:

Follow-UP AssessmentType = TEACHING


Admit/Assess Educ


Ongoing Education


Medication Education

Assessments of Wounds are done in the Wound Assessment Type. Click on the “Perform Assessment” Icon Select the Wound Assessment

The Wound Management Window will open. If this wound has been documented and this is the wound you are assessing simply double click on that site. If it is a “NEW” wound, click on the scroll in the secondary toolbar.

Wound AssessmentType


If documenting on an existing wound when the assessment opens, the top half reveals the baseline Wound Info (it is not editable). The Site Assessment is on the lower half and reveals the last assessment completed. To start a new site assessment click on the Insert button. To view assessments prior click on the arrows at the bottom of the screen.

The new Site Assessment will open to allow for documentation. When completed, click OK and the assessment will close


If documenting a “NEW” wound, click on the scroll in the secondary toolbar. The top half of the screen “Wound Info” is the baseline wound information

and once saved this cannot be changed. The bottom half, “Site Assessment” is the nurses assessment of that wound. Once completed click OK to close the assessment.

Flow Sheet (Vital Signs, I/O’s, Measurements, and IV insertions)

In the CareGlance screen double click on the FS bubble

When the Flow Sheet screen opens right click in the “white” space to select what you need to do.

Vital Signs:

Flow Sheet (con’t.)

Enter your vital signs and then click “OK” at the bottom of the screen

I/O’s:


Enter your I/Os and then click “OK” at the bottom of the screen

IV Management


IV Site List Screen will open. Click on New IV Site and then OK

The IV Site Screen will open and the Started By Field will default to you.

Click the drop down arrow to choose the IV Site

Click the drop down arrow to choose the IV Type Enter Catheter size Enter Site Started Date and Time Areas in Bold must have entries


IV Management

Click the OK at the bottom of the screen

IV Entry: Do you want to save your changes? Click Yes


IV Management

The Fluid Screen will be available to add Fluids if you are hanging a bag at the time of IV Insertion.

Enter Fluid Type (i.e. NS) Fluid Started By defaults to the user Enter Starting Volume Enter Rate

Then Click OK and Save your changes.


IV Management

Assessment of IV’s is in the Daily Assessment under the Intravenous Tab

The IV Assessment looks like this. Click on the IV Site you are assessing and complete the fields.

IV Management

There are two tabs in Order Management (OM) that we will cover. One is the “DIET” Tab and the other is the “Inquiry” Tab.

To access OM highlight your patient in Clinical CareStation (CCS).

Click on the OM Icon (aka “Pizza Hut”) in the Primary Tool Bar. This will open the OM Application and the Order Entry Tab is defaulted.

Order ManagementApplication

Click on the Diet Order Tab to view your patient’s diet order.


Click on the Order Inquiry Tab to view ALL orders that have been placed on your patient as well as see results. To view results, highlight the order you wish to review and click the “Results” button to the right of the screen.


Critical Result

Resulted (no ranges)

Normal

Abnormal (out of range)

ADMINISTERINGMEDICATION(S)

AdministeringMedication(s)

The Medication Administration Application can be accessed two different ways.

The Most Common way is through the Rx Bubble on CareGlance Screen

The other option is to click on the Medication Administration Icon in the Primary Tool Bar

Identify your patient w/ two identifiers – Once the MAR is loaded – Scan your patients

armband.

1

Scan the Medication(s) you wish to administer

to the patient

2



A Lock will appear on the Admin. column.

Medication(s) are now “PENDING”


Go to “Pending” Folder to verify that medication(s) were scanned. Look for a green checkmark to the

left of medication(s) scanned.

Click “Confirm” after reviewing that Total Scan matches Ordered Dose (The example

here is different as patient only wanted 1 Tylenol). Complete Administration Screen to

include any edit boxes that are required (i.e. Early/Late Doses)

1

2


Once you click “confirm” the Administration Window will open (5 rights, PRN Reasons, Late Dose Code, etc.) Areas that must be completed will be BOLD.


You are Ready to Administer Your Patient’s Medications

After Administering your Patient’s Medication Click the CHART Button! If you don’t, the

medications will go back into the eMAR like they were never given.

Don’t Forget…

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