PHRED Handbook For Clinical Instructors & Students PDF

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PHRED Handbook for Clinical Instructors & StudentsxStudent Documentation GuidelinesStudents will document assessments, medications, and patient cares in the Electronic Health Record,PHRED, while at Children’s Mercy Hospital. Students will chart assessments based off of systems and norms set by Children’s Mercy Hospital. Students will chart: system assessments, vital signs, measurements (Ht, Wt, HC), intake & output(IV fluids only with RN), basic cares (bed, bath, linen, oral care, turning, ambulation, etc),procedures performed, and medications administered. Students should communicate all information with the staff in a timely manner in addition tocharting. The student should initiate a conversation with nurse to review their documentationbefore leaving the unit. A clinical instructor and/or nurse MUST Validate/Authenticate ALL student charting andmedications, after reviewing with the student before students leave for the day. If changes are needed the student should make these changes at this time.The School is responsible for verifying that all students complete the following before starting clinicalrotation:1. Watch Training Videos2. Review Training Material3. Complete Training Quiz- retain for school records onlyFirst day of clinical/orientation the following must be completed to have access to systems:1. Set Up Network Login & Password- below2. Set Up Patient List (specific to your area)Creating a Network LogonYou must be in the hospital to be able to set-up your network logon.1. Start at the login screen for a computer. If the computer is already on the desktop use Ctrl Alt Deleteor Switch User.2. Enter username: (this was given to you by your school/instructor)3. Enter password: (this was given to you by your school/instructor)4. You will be prompted to enter a new password, enter new password, & Confirm.5. Once you have set-up your new password please Log Off the computer.You will now be able to use this username and password to access the Intranet at Children’s Mercy on anycomputer without signing into the computer.Updated: 6/3/20201

PHRED Handbook for Clinical Instructors & StudentsNavigationReview of CARECOMPASS (List of patients) Patient Listo Drop down menuo Top selection defaults openList Maintenance - Adjust Patient ListorderEstablish Relationship –o Select Relationshipo Select EstablishUnit Listo Location - Room and bed number (organize ascending or descending)o Patient - Name, age, sex, resuscitation status, allergies, diet (organize ascending or descending)o Visit - Reason for visit and length of stayo Care Team - Attending’s for this encountero Med Calc Weighto PEWS - Result changes colors when score increaseso Cardiac PEWS - Result changes colors when score increaseso Patient Discharge - Discharge order signed then date of order will populate(replaces person icon)o Activities - Taskso Hover to discover - See more informationNew orders and resultso Orange box - New orders or resultso Red box - STAT orders or results Click on exclamation point to openUpdated: 6/3/20202

PHRED Handbook for Clinical Instructors & Students Activities (Tasks) Access Task List from Patient or Activities columno Use Task List inside chart to documentCARECOMPASS IconsIcon IdentificationNurse ReviewImmediate Priority: STAT/NOWorders.Critical Results: Indicates Criticalresults for a patient.High Result: Normalcy indicatorindicates result is High.Low Result: Normalcy indicatorindicates result is Low.Non-Critical New Information:Indicates new non-critical results ororders for a patient.Critical New Information: Indicatesnew critical results or STAT orders.High Risk Alert: Indicates thepatient has high risk indicators.Placing your pointer over this iconshows additional information aboutthe high risk indicators.Isolation: Hover to see isolationtype(s).Patient is confidential: Hover to seereason.Updated: 6/3/20203

PHRED Handbook for Clinical Instructors & StudentsReview of the Patient ChartDouble click on the patient name to access patient chart. This is where you will obtain your current & historical clinical information. Ifmenu is not visible, hover over menu tab and click on push pin to keep open.BandDescriptionMPagesView a brief summary of patient information and assessment.View Current Orders to guide your care Under Display select All ActiveOrdersOrdersAdverse ReactionsUsed for charting and view of I&O 24hr totalsView I&O Totals1. Click on I-View Section2. Click on I&O Band (towards bottom)3. Scroll to right to see last 24hr intake (blue columns)View reactions and allergiesMARUsed for obtaining Med List & for Med AdministrationMAR SummaryView last administered medication dose/timeHelps organize tasks to complete. Use this to document labs, & weights(unit/shift dependent). DO NOT document oral care or baths from here.History & Physical, Progress Notes, Consult Notes, etc.If H&P is not listed – change time frame to look closer to admit date.(Right click on time range bar and select Change Search Criteria, Selectdates around admit date.)Change timeframe (use arrows to move date)Lab Results- double click on result to view normal high and low resultsRadiology Results (click on test to view results)Recent Results – View Clinical DocumentationAll Results Flow sheetView Patient Weight & Height/Length (under 3 years)1. Click on Measurement2. Click Table to view all entriesView past visitsI-ViewTask ListDocumentsResults reviewGrowth ChartPHRED Toolbar:Patient Info/VisitsLexi-Comp: Medication Information & PathophysiologyClinical Skills: Nursing Skills- Procedures & Nursing Consult- EducationSCOPE/ Policy Manager: Children’s Mercy intranet, find Policies and ProceduresMedication Administration: Bar Code Medication Administration, click here and then scan medication at administrationLearning Live: Access help with documentation from inside PHREDUpdated: 6/3/20204

PHRED Handbook for Clinical Instructors & StudentsViewing Documentation from Results ReviewFrom the Patient’s Chart click on Results Review (Note tabs across the top)Lab- To change the search criteria so you can see more days, Right click Clinical Range bar, change search criteria, select datesRadiology- To change the search criteria so you can see more days, Right click Clinical Range bar, change search criteria, selectdatesRecent Results Tab- documentation from I-View and DocumentsInfection Control Devices- documentation related to Hospital Acquired ConditionsPatient Family Education- documentation done related to education of patient and familyGraph icon- shows results in a graph formatSort by Table, Group or List- Changing the way the screen is viewed (Group or List) makes finding data easier. Examples:Heights & WeightsChoose your Flowsheet- Clinical Info defaults open and shows all sections with clinical documentation. There are manyoptions for more specific views: Vitals View Pulmonology View Diabetes FlowsheetUpdated: 6/3/20205

PHRED Handbook for Clinical Instructors & StudentsReview of the eMAR (REVIEW and play with to make bullets match screenshot)The eMAR is to be used as the source of truth. Good practice includes checking all rights on MAR as a first step before scanning. Meds are organized by scheduled, unscheduled, PRN, continuous infusions, & discontinued Blue Boxes indicate a medication dose is due Red Boxes indicate medication is overdue or STAT Green Boxes indicate a PRN medication and the last given information Gray Boxes indicate a dose scheduled beyond the next scheduled dose. The location of the medication is listed with the medication details (i.e., 6H2 – Pyxis or Med Drawer). Check your 5 Rights here on all your medications, even when Bar Code Medication Administration is used. Medications are considered on time at Children’s Mercy Hospital when given within 30-60 min of the scheduled time. Please notethis depends on the medication and you should note time critical and time sensitive medications.o1.2.3.4.Medications can be rescheduled by the nurse using Reschedule Admin Times. Talk with patient’s RN to ensure anappropriate schedule.Previous administration documentationa. Shows in time in that time columni. 8/15/2019 @ 0911b. Shown in future task boxes (#3)Current time columnTask boxa. Use this to document current dose, if not using MAW for BCMAb. Will show when a previous dose was given or if Not given within 8 daysFuture dosesa. Greyed outb. Can’t document on the task, informational onlyUpdated: 6/3/20206

PHRED Handbook for Clinical Instructors & StudentsDocumentationDocumentation on the eMARAt Children’s Mercy Hospital we use Bar Code Medication Administration to assist in our delivery of medications. Our number one priority is patient safety. BCMA adds one more safety check in the medication administration process Scanning does not replace use of the eMAR and checking your 5 rights The eMAR will still be available as a resource and to be utilized as the source of truth BCMA is not intended to speed up the medication administration processView the Bar Code Medication Administration Training video & handouts for medication documentation utilizing scanning technology.Documentation of Assessment & Procedures in I-ViewI-View, is where most documentation occurs. I-View is organized by bands and sections and will vary depending on your position in the system.The colored clinical range bar is set to a specific time frame and can be changed by right clicking. The time columns arealso set to specific time frames and can also be changed by right clicking.Basic NavigationTo document in I-View you need to activate the column1. Double click on the time to activate time columnNote the white boxes and check marks in all sections 2.Click in area you want to document3.Sign by clicking on Green CheckmarkOther commonly used icons:Takes to previous location in systemView only documented values by selecting Show Empty Columns/Rows ButtonStops and clears documentation, without signingUpdated: 6/3/20207

PHRED Handbook for Clinical Instructors & StudentsAssessment DocumentationAssessments are done by documenting system norms. Assessment findings that are not normal are documented in othersections of I-View often below the Norms. In the example below the patient is not on room air so it is not selected and thenOxygen information is documented elsewhere.Printing Lab LabelsTo complete lab label view: Collections Inquiry- Pathnet Barcode Labels Demand PrintCompleting a Procedure on the Task List Task list helps to organize your day, like an electronic brain.Task “Performed on” date/time will default to the date/time the task is scheduled.You will complete some procedures from in task list, for example lab draws.DO NOT document Mouth Care and Bathing on the Task List.It’s important to NEVER document medications from the Task List.Complete a Task:1. Click on Task List from the Menu2.Right click on task you want tocomplete and click Chart Done.Completing Lab Task: When documenting lab draw you will need to verify Date, Time, andPerformed by then Click OKUpdated: 6/3/20208

PHRED Handbook for Clinical Instructors & Students Updated: 6/3/2020 5 Viewing Documentation from Results Review From the Patient’s hart click on Results Review (Note tabs across the top) Lab- To change the search criteria so you can see more days, Right click Clinical Range bar, change search criteria, select dates Radiology- To change the search criteria so you can see more days, Right ...