Patient Care - Reference Manual - Physician - Fraser Health Authority

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CHAPTER 2 – ENTER / EDIT PATIENT DATA1. Enter/Edit Patient DataIt is the clinician’s responsibility to maintain the accuracy of the information contained onthe Patient Data screens by updating them every 24 hours. Some of this information,such as height and weight, and allergies passes to other applications and is important inthe treatment plan for the patient.1) From the Nursing Main Menu desktop, click the ENTER/EDIT PATIENT DATA icon.2) The Enter/Edit Patient Data menu opens.a) Click on Enter/Edit Patient Data or highlight it by using the keys and pressthe key.3) This opens the Enter/Edit Patient Data routinea) Enter/Edit Patient Data Screen is a routine in which the clinician can enter,update and review clinical information for patients assigned to their unit.Health InformaticsHealth Information Systems and Services© Fraser Health Authority, 2006. All rights reserved.10
) There are three tabs in Enter/Edit Patient Data routine: Standard Fields, Custom Queries, and Allergies/Adverse Reactions.c) The Standard Fields Tab – (as pictured on page 10) is the tab that is selected by default.The Custom Queries and Allergy/Adverse Reactions tabs will be greyed out, notallowing clinician access. Once a patient name has been entered, the clinicianwill have access to all the tabs.Fields in the Standard Fields TabTemporary LocationHold TrayConditionVisitors AllowedCondition CommentVisit ReasonHeight and WeightTemporary Location is used to enter a location where thepatient is going on a temporary basis e.g. OR. This allows thetemporary location to enter orders for the patient. Only thoselocations that are patient care units must be entered as atemporary location. Therefore, if the patient is going for aspecial procedure, or ultrasound, it is not necessary to placethe patient into a temporary location. Pressing the lookup key or will list all locations by their mnemonic. See thesection called Enter/Edit Temporary Location for further detailson the use of this function.Not to be used. Please leave blank.The Condition field provides Patient Information, Admitting, andSwitchboard with information regarding the patient’s condition.The condition choices are available by using the look upkey or , e.g. critical, serious, good, and fair.This field informs Patient Information, Admitting, andSwitchboard about visitor status and may prevent a phone callto the patient care unit. This field is answered with a Y yes or Nno.No private or confidential information is to be entered in thisfield. The Condition Comment is intended for general patientinformation only. This field can be used for further informationabout visitors e.g. family only, or information about patientwhereabouts. The information goes to Patient Information,Admitting, and Switchboard.This information is the initial reason for the patient’s visit tohospital, as entered in the Admitting system. This field is forinformation only and cannot be edited by NursingThis field provides Pharmacy and other receiving departmentsthe patient’s height and weight. The height and weight areautomatically changed into metric if entered in standardmeasures and vice versa. Once the information is entered, it willfollow all orders placed for the patient.Health InformaticsHealth Information Systems and Services© Fraser Health Authority, 2006. All rights reserved.11
Page 1 and 2: Patient Care - Reference ManualNurs
Page 3 and 4: CHAPTER 1 - INTRODUCTION1. Introduc
Page 5 and 6: 4) A pop-up box will display titled
Page 7 and 8: 3. What is the TOOLBAR?The toolbar
Page 9: 5. How do I change my PASSWORD?1) F
Page 13 and 14: e) The Allergies/Adverse Reactions
Page 15 and 16: 2. Patient Allergy and Adverse Reac
Page 17 and 18: 4) Enter the patient name (Note: Th
Page 19 and 20: The Active Function ButtonsE - Ente
Page 21 and 22: g) Quantity (Qty) - the field displ
Page 23 and 24: 3. Introduction to the Care Area Or
Page 25 and 26: 4. Entering a Basic Order1) Choose
Page 27 and 28: 6. Entering Series OrdersSeries Ord
Page 29 and 30: 4) After you select an order set, a
Page 31 and 32: 9. Reviewing Duplicate OrdersA ‘D
Page 33 and 34: a) If unsure of the category mnemon
Page 35 and 36: MATERIALS REQUIRED Downtime Requisi
Page 37 and 38: ReportPatient Order SummaryUnverifi
Page 39 and 40: 2. Introduction to Printing Medicat
Page 41 and 42: 4. Printing MARs for Selected Patie
Page 43 and 44: 6. Introduction to Printing Medicat
Page 45 and 46: 8. Printing Medication Profiles for
Page 47 and 48: 10.Listing Pharmacy Floor Stock & N
Page 49 and 50: 3. The Basics of navigation in EMRI
Page 51 and 52: 2) Recent Access Menu Option - The
Page 53 and 54: 6. A Word about Selecting ‘Visits
Page 55 and 56: 2) The Menu Frame - The Menu Frame,
Page 57 and 58: e) To view a snapshot screen of a g
Page 59 and 60: 7) Order History Panel - use the Or
Page 61 and 62:
i) Blood Bank Tests panel is used t
Page 63 and 64:
iv) Patient height (Standard and me
Page 65 and 66:
GLOSSARYAccessAdmissionStatusButton
Page 67 and 68:
InterfaceLocationThe ability to pas
Page 69 and 70:
RoutineService DateSessionTabTimeUn
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