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 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 Objectives

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. 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 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 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 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) Brachial (Upper Arm) Femoral (Groin) Popliteal (Knee) Tibial Apical (Heart) Radial (Lower Arm) Ulnar (Wrist) Dorsalis Pedis

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.

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.

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 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.

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 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 patient’s 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.

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.

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 patient’s oral intake with lunch. Note the blue text in the answer section for this question. It tells us to document a patient’s 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 patient’s Intake and Output as you go, not just at the end of the shift. Remember, we will not document our patient’s 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 patient’s input and output, we will click on the Return button.

We have been returned to our Intervention Worklist. We are finished documenting our patient’s Meal Intake and I&O 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.

Let’s 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 hasn’t 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 patient’s 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.

Let’s 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 haven’t 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.

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.

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 patient’s 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.

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.