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PCD TRAINING MANUAL
What is PCD??
“Patient Care Documentation”
Computerized nursing documentation
Developed by Siemen’s 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.
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.
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 S&W as a student.
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
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 different functions 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.Can NOT chart in the future
Use spin buttons or type In the values
Move from field to field using mouse or tab key
Charting Vital Signs
To add more vital signs,Click here. Click update complete to chart
Click on cancel to exit pathway without entering data.
Revise Vital Signs
Indicates the person Entering the data
Vital signs are grouped in reverse chronological order.
Revise Vital Signs
From the vital display, select vs to be revised Then click on revise.
Revise/Delete Vital Signs
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 andClick OK
When using Mark as Error,A reason must be entered.
Using skip button allows userTo leave screen without makingChanges.
Display Vital Signs
This displays the last 5 sets of VS. To see all since admission, click all.
Revised VS will display this way
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
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 I&0
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
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 andClick 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 addedSources marked exclude will not show in the total
CMST ChecksRestraint Documentation
CMST Checks
Document Restraint data here
Change date/ time as needed to reflectrequired q 2 hour restraint documentation.
Items click yes require description
Document interventions every 2 hours and add comments as needed
Click update complete to store data
Chart Assessments
Admission/Shift/Focus Assessment
Create New Assessment
LVNs do not have discharge assessment listed.
Select assessment type and click begin
Date and time should reflectactual date and time assessment was performed.
Admission Assessment
From this screen document Admission History, Admission assessment, and other needed assessments, ie, pain/ comfort or restraints.
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.
Select chart detail to continue
Last chance to modify date and time.
Admission History
Opt Out is a mandatory field
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
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 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 Advance Directives is a required field
Admission HistoryPast Medical/Surgical History
Be sure to assess immunization status on admissionClick on Pneumo/Inf to access the Admission AssessmentHospital Order form and immunization information.
LVNs may only select Update PendingUpdate Complete will be grayed out
Enter date of vaccination if known,You can check DWP for immunization date status if unknown.
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.
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
AssessmentEdema
Click the “Grade” buttonfor definitions
AssessmentBraden Scale
Braden scale must be assessed every 24 hours
Document any skin abnormality from 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.
Click here to access fall prevention guidelines.
Assessment Storing Data
Select update/complete or update/pendingto save entered data
Assessments that were visited are underlined
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
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
View Assessments
Click to view assessment, select assessmentand click view.
View Assessment
This is how datadisplays when View Assessments selected
Change/Delete Assessment
Select the assessment to be changedor 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 assessment
Only delete your own assessments.
Guidelines for Delete Assessment
Use Delete when you have charted on the wrong patient.
Delete only your own assessments
Copy Assessment
Select copy an existing assessment Select assessment to be copied.Click copy.
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.
Complete Pending Assessment
Select complete assessment, choose assessment in pending status (P), and 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 administration of vaccine
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
Take ever opportunity to learn.
Be safe out there!