PCD TRAINING MANUALLicensed Staff

What is PCD??

“Patient Care Documentation”Computerized nursing documentation developed by Siemens’ companyOn all hospital units except for ICU, ED, Labor & Delivery, Post partum, NICU.Adult ICU & PICU use the admission history section only.

System Sign-onThe User ID & password are your legal signature. Always log off when the transaction is complete. Never allow anyone else to use your password.Contact the Help Desk (4-2501) or log into Passport to change your password*.A record is kept of all transactions.

Your Sign-on is last three characters of your mainframe sign-on;example: 123ABC

Your Password is your mainframe password: random letters & numbers assigned by IS.*

Nurse Station Census

The unit census defaults to where the user signs on.

Net Access navigator bar.Can be used to locate patientsby name or MRN inquiry.

Nurse Station Census

Patients are listed in Room/Bed order, Name highlighted in blue and underlinedClick once on the patient name to select patient.

View census of another unit by selecting Unit Census from the Navigator Bar and choosing the unit

More Navigator Facts Once a patient is selected, differentfunctions 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

Vital Signs

Charting Vital Signs

Defaults to current time,may change date and time.May chart past 48 hours.Can NOT chart in the future

Use spin buttons or free text the values

Move from field to field using mouse or tab keyThese are now mandatory

Charting Vital Signs

To add more vital signs, Click here.

Click update complete to chartThis is your “save” button

Click on cancel to exit pathway without entering data.

Three places available for orthostatic B/P’s

Now mandatory

Revise Vital Signs

Indicates the person Entering the data

*****Only Licensed Staff can revise vital signs:RN anyoneLVN only their ownCNA cannot at all

Revise Vital Signs

From the vital display, select data to be revised Then click on revise. Only licensed staff can revise:RN revises anyoneLVN revises only their ownCNA cannot revise at all

Revise/Delete Vital Signs

Choose a radio button:1. Revise result to change incorrect data on correct patient.2. 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

This displays the last 5 sets of VS.

To see all since admission, click all.

Revised VS will display this way showing Incorrect data as well as corrected data.

Vital Signs mark as an error display this way

Intake and OutputI&O

Entering I&O

Enter the date/ time I & O collected

Enter amount of intake or output in mls

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 (it cannot be deleted).

Excluded sources are not included in the I/O totals.An “X” will display in the excluded column. IE Stool Count Click OK to store data

Select Add Comments to Enter additional data about I&0

Approximations will not be added to totals.

They will appear as “+”.

Comments

A comment field is providedFor each I&O sourceClick OK when completed

Intake & Output Sources

Select intake or output to add sources

Click Add when desired sources have been selected

Revise I&O

Only licensed staff can revise:RN revises anyonesLVN only their ownCNA cannot revise at all

Select the item(s) to be revisedClick revise

Shows the date/time interval for the displayed data.

T indicates comment

Revise I&O

Choose radio button:1. Revise result to change incorrect data on correct

patient.2. 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 userTo leave screen without makingchanges.

Display I & O

Shift times in columns link to additional information

“T” indicates a comment was added.Sources marked excluded will not show in the total

Chart Assessments

Admission/Shift/Focus/Discharge Assessments

Create New Assessment

Select assessment type and click begin

Date and time should reflect actual date and time assessment was performed.

******Documentation choices depend on job title.

Admission Assessment

From this screen document Admission History, Admission assessment, ad other needed assessments, ie, pain/ comfort or restraints.

Selecting ‘Required Assessments’ automatically selects the Admission History, Body Systems, Fall Risk, Pneumonia/Flu, Sepsis Screening and Education. Others may be selected as needed. Each system displays in the order they appear on this screen.

Select chart detail to continue

*****Assessments can only have one time assigned to that assessment. If the LVN does the adm hx, RN who completes the admission must time her assessment at least 1 minute later.

Admission History

Opt Out is a mandatory field.Answering “yes” only indicates thatyou have offered the patient the optionnot whether they want to opt out or not.

Arrival Date/Time must be entered

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

‘…’ indicates additional screens will appear if the item is selected

Adult ICU, PICU and CCH only do Admission History,

Admission History Personal Belongings

You must describe clothing, cash, jewelry, other

Location is mandatoryif the field is selected

Use these buttons to move between screens

Admission HistoryNutritional Screening

Selecting any of these will send a consult to Nutrition Services

Not required but useful information

Admission HistoryChaplain Referral

Selecting “chaplain referral” will generate automatic consult

These fields are mandatory.Cannot move forward until completed

Admission HistoryContinuum of Care

Anticipated discharge placement

Selecting any of these will generate a referral

Admission HistoryAdvance Directives

Executed Advanced Directives is a required field

Admission HistoryPast Medical/Surgical History

LVNs may only select “Update Pending”Update Complete will be grayed out

Enter date of vaccination if known,You can check ‘Immunization History” in Navigator bar for immunization date status if unknown. This is S&W info only.

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

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

Pneumococcal Screen

Screens are age based:Either > 65 yrs of age or18 – 64 yrs of age

18-64 yr old must have a chronic illness to qualify.Chronic illness box lists example diagnosis

Patients in SWMH ICU are not screened for vaccinations

This question refers to this group or questions only

Flu Screen

Verify that months are within flu season

Verify if flu vaccine already given this flu season.Refer to immunization history in navigator bar.Make sure you update/ pend before opening immunization history as it will kick you out and will lose everything you just entered.

H1N1 ScreenH1N1 to be given until further notice from Administration

Patient must:1. Review H1N1 protocol2. Meet protocol3. Consent to vaccine

If any of these do not occur, patient does not receive vaccine

AssessmentWithin Defined Limits (WDL)

“WDL All” indicates your assessment meets the defined limitsSelect “except for” to document exceptions to WDL.

Assessment Cardiovascular

Most selections can be entered via the point and click method using the radio buttons,Checkboxes and free-text data entry fields

Remember any choice with“…”, additional screens will need to be completed

AssessmentEdema

Click the “Grade” buttonfor definitions

AssessmentBraden Scale

Braden scale must be assessed every shift

Document any skin abnormality on this screen

Braden Scale

Click here to access skin care policy

Select either tab or button

Select appropriate descriptor or free text number in box

Click “Close” or “Continue” to see Braden total score

AssessmentFall Risk

You must select either “no fall risk” or one or more of the risk factors listed to proceed.

Fall Risk Interventions Screen

Standard precautions always necessary for a fall risk patient.

Then, choose any other precautions done to protect patient

Initial Restraint Documentation &Every 2 hour CMST Checks

Initial Restraint AssessmentRestraint assessment must be made prior to applying restraints. Document all actions taken prior to application of restraints.This is usually a “focus “note

Family and patient must be informed of reason for restraint usage

Restraint Assessment

Document all alternatives tried and responses to those

Restraint Assessment

Initial CMST (Circulation, Motion, Sensation, Temp) check

RN must assess for continuation of restraints or not

Every 2 hour CMST Checks

Document Restraint data hereChange date/ time as needed to reflect required q 2 hour restraint documentation.

Items clicked yes require description

Document interventions every 2 hours and add comments as needed

Click update complete to store data

Sepsis ScreeningShift and Focus

This is an example of a patient who is septic but not in severe sepsis or in shock.This screen walks you through the process of identifying a patient who is either: 1.septic (has an infection UTI, Pneumonia, wound infection)2.In severe sepsis3.In septic shockThis is done q shift on all units. If a patient’s status changes, can be a focus note.

This identifies that the patient has more than 2 SIRS and a known or suspected infection. The patient has not had a serum lactate greater than 4 or organ failure

Positive Sepsis ScreenThis screen has identified a patient who has gone from severe sepsis to shock.1.The patient had 2 or more SIRS with a suspected or known infection2.A lactate acid or 4 or greater within the last 24 hours3.Patient has not had response to fluid challenge to increase B/P4.Patient has one or more organ failures.

Identification of Severe Sepsis or Septic Shock will trigger the pop up box to notify PCP and call a Dr. Rapid.Make comments in the comment box as to what was done in regards to this patients positive screen.

Assessment Storing Data

Select update/complete or update/pendingto save entered data

Assessments that were visited are underlined. Last chance to go back and address any initial assessment you may have missed.

Shift/Focus AssessmentsAdmission History not an option on this screenRequired assessments include body systems, fall risk and educationOther options, ie, Peripheral IV, Pain/Comfort, etc. may be added as appropriateAll other steps are the same as the admission assessmentSee next slide

Shift/Focus AssessmentsIf 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

View Assessments

Click to view assessment, select assessment,and click view.

View Assessment

This is how data displays when “View Assessments” is selected

Change/Delete Assessment

Select Change/Delete Assessment,the assessment to be changed or deleted, then click the appropriate button for that function.

Change Assessment

Only change your own assessments

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

This is the final screen before you delete an assessmentOnly delete your own assessments.

Guidelines for Delete Assessment

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

Complete Pending Assessment

Select “Complete Assessment”, choose assessment in pending status (P), then click complete.

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 Assessment

This question asks if immunization status was assessed.

Indicates if administration of vaccine occurred.

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

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