Eclipsys Clinical Documentation

Clinical Documentation
Introduction to:
Flowsheets
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Introduction
• This slide show is designed to give you a
basic overview of Flowsheets in SAC
(Sunrise Acute Care) system, before
attending class.
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Background
• Eclipsys electronic clinical documentation
is generally a “point and click” system that
allows you the user to chart simple to
complex notes with just a few clicks of the
mouse
• This slide show will provide an overview
the terminology and mechanics of
entering data into flow sheets.
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Overview
• All of our documentation should work
together to form a picture of our patient’s
condition, treatment, and outcomes.
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Admission
Assessment
Care Plan
Med Admin
Orders &
Results
Daily Nurses
Notes
Patient
Education
Ancillary
Depts
Procedures
Discharge
Planning
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Flowsheets
• A flowsheet is a document that contains
information that is entered repeatedly
across time, such as Vital Signs and I&O.
• It is usually set up in a grid format with
time columns.
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Vital Sign Flowsheet
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What do they all MEAN??
• There are lots of new
terms you will hear
when learning about
flowsheets
• Time Columns
• Observations
• Parameters
• Lists
• Cell
• Value/Data
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Flowsheet Terms
Time Column
Observation
Parameter
Value/Data
Cell
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Flowsheet TAB
• To get to the flowsheet, first select your
patient from the patient list then select
Flowsheet from the tabs
• or the icon
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Documenting on a Flow Sheet
• To chart on a
flowsheet you
must choose the
correct
flowsheet from a
list in the lower
left corner
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Adding a Time Column
Time Columns may already be created on the flowsheet
when you open it. However there may be situations,
where you may have to add a time column. Examples
would be charting a follow up pain assessment or your
patient becomes feverish.
To add a time column:
1. Right-click on the top of any time column.
2. Select Add New Time Column
3. In the “Set Date Time” dialog box, choose the appropriate
date and enter the time.
4. Click OK.
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5. Your new column should now appear on your flow sheet.
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Right Click
Here
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Type in the
time here
and click OK
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New Time
Column
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Observations
• What are Observations?
• Observations are the data elements clinicians
collect about patients
• Temperature
• Blood Pressure
• Pain
• All are examples of Observations.
• Sometimes they are also called parameters
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More about Observations
(they must be important)
• Some observations are on the flowsheet as soon
as you open the flowsheet
• These are observations that all patients need to have
documented.
• Temperature, heart rate, blood pressure, are examples of
these types of observations.
• Some observations have to be added
• These are observations that not every patient would
need charted
• Capillary glucose would be an example
• If the observation you need isn’t on the flowsheet it must be
added.
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Adding an Observation Parameter
1. Right-click on an observation parameter or in the
gray area at the top of the flowsheet
2. Choose “Add Parameter” from the drop-down list
3. A box opens with the parameters available to be
added to the flow sheet
4. Click on the parameter(s) in the left box and click
the Add button.
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Right Click in
This Area
Select add
Parameter
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Add the observation
you want from this
side, then click add,
then click OK
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The new
Observation
is added to
the flowsheet
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Documenting an Observation
1. Some observations are numbers
• Temperature, Heart rate
2. Some are values picked out of a list of choices
• Pain location, Blood pressure reading location
3. Sometimes, the value you want won’t be on the
list and you must type it in.
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Different ways of charting an
Observation
• The (degrees F) observation is a numeric
value noted by the ### in the cell
• You can only type numbers when you see this
type of observation
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• The site however, is a list value.
• Click in the circle (also called a radio
button) and select where you took
the patient’s temperature.
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List Choices
• SAC uses 2 types of lists: suggested and
restricted. Note the Restricted list does not have
an empty box at the end of the list
Restricted, you must
select a choice provided
Suggested, you may
select a choice or type one
of your own in the box
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• In the previous slide I typed “PVC” in the
box, here is how my choice is displayed:
• When the cell is too small to display the
value a blue arrow is displayed, hover with
the mouse to see the value
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More about Lists
This box filters the
list choices to find
the one you need
quickly
By typing
“L” in the box
now you can
only see the
choices that
start with “L”
from the list
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Again if your choice
isn’t in the list
you can type your own
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One more thing about Lists
• Sometimes you can choose more than one choice
from a list.
A list with radio buttons (circles)
means you can only
choose one choice in this
list
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A list with check boxes (squares)
means you can choose one or more
choices from the list
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Ok, I’ve entered my information
now what?
Once you’ve entered
your observations, click the
Save button
• After you select save, enter your password, and
you are done.
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What do the arrows mean?
A single or set of two red arrows display
above your observation, this means that the
observation is out of range—high or low—to
alert you of the fact. A double red arrow
means a critical value.
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What if I make a mistake?
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Oops!
Nobody is perfect, so there will be times when you will
need to correct your work. If you make a mistake,
simply click on the cell where you need to make the
change and enter the correct information.
Remember, you must save your work before leaving
the flowsheet.
A red C will display above any corrected data.
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Conclusion
• This ends the intro to Clinical
Documentation Flowsheet slide show
• This slide show is not intended to replace
classroom training or practice, it is only to
serve as preview of the system prior to
attending class.
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