pcd training manual licensed staff
DESCRIPTION
PCD TRAINING MANUAL Licensed Staff. What is PCD??. “Patient Care Documentation” Computerized nursing documentation developed by Siemens’ company On all hospital units except for ICU, ED, Labor & Delivery, Post partum, NICU. Adult ICU & PICU use the admission history section only . - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/1.jpg)
PCD TRAINING MANUALLicensed Staff
![Page 2: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/2.jpg)
What is PCD??
“Patient Care Documentation”Computerized nursing documentation developed by Siemens’ companyOn all hospital units except for ICU, ED, Labor & Delivery, Post partum, NICU.Adult ICU & PICU use the admission history section only.
![Page 3: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/3.jpg)
System Sign-onThe User ID & password are your legal signature. Always log off when the transaction is complete. Never allow anyone else to use your password.Contact the Help Desk (4-2501) or log into Passport to change your password*.A record is kept of all transactions.
Your Sign-on is last three characters of your mainframe sign-on;example: 123ABC
Your Password is your mainframe password: random letters & numbers assigned by IS.*
![Page 4: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/4.jpg)
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.
![Page 5: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/5.jpg)
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
![Page 6: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/6.jpg)
More Navigator Facts Once a patient is selected, differentfunctions 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
![Page 7: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/7.jpg)
Vital Signs
![Page 8: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/8.jpg)
Charting Vital Signs
Defaults to current time,may change date and time.May chart past 48 hours.Can NOT chart in the future
Use spin buttons or free text the values
Move from field to field using mouse or tab keyThese are now mandatory
![Page 9: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/9.jpg)
Charting Vital Signs
To add more vital signs, Click here.
Click update complete to chartThis is your “save” button
Click on cancel to exit pathway without entering data.
Three places available for orthostatic B/P’s
Now mandatory
![Page 10: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/10.jpg)
Revise Vital Signs
Indicates the person Entering the data
*****Only Licensed Staff can revise vital signs:RN anyoneLVN only their ownCNA cannot at all
![Page 11: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/11.jpg)
Revise Vital Signs
From the vital display, select data to be revised Then click on revise. Only licensed staff can revise:RN revises anyoneLVN revises only their ownCNA cannot revise at all
![Page 12: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/12.jpg)
Revise/Delete Vital Signs
Choose a 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 and Click OK.
When using Mark as Error,A reason must be entered.
Using skip button allows user to leave screen without making changes.
![Page 13: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/13.jpg)
Display Vital Signs
This displays the last 5 sets of VS.
To see all since admission, click all.
Revised VS will display this way showing Incorrect data as well as corrected data.
Vital Signs mark as an error display this way
![Page 14: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/14.jpg)
Intake and OutputI&O
![Page 15: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/15.jpg)
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 (it cannot be deleted).
Excluded sources are not included in the I/O totals.An “X” will display in the excluded column. IE Stool Count Click OK to store data
Select Add Comments to Enter additional data about I&0
Approximations will not be added to totals.
They will appear as “+”.
![Page 16: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/16.jpg)
Comments
A comment field is providedFor each I&O sourceClick OK when completed
![Page 17: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/17.jpg)
Intake & Output Sources
Select intake or output to add sources
Click Add when desired sources have been selected
![Page 18: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/18.jpg)
Revise I&O
Only licensed staff can revise:RN revises anyonesLVN only their ownCNA cannot revise at all
Select the item(s) to be revisedClick revise
Shows the date/time interval for the displayed data.
T indicates comment
![Page 19: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/19.jpg)
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 and click OK
When using Mark as Error,A reason must be entered.
Using skip button allows userTo leave screen without makingchanges.
![Page 20: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/20.jpg)
Display I & O
Shift times in columns link to additional information
“T” indicates a comment was added.Sources marked excluded will not show in the total
![Page 21: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/21.jpg)
Chart Assessments
Admission/Shift/Focus/Discharge Assessments
![Page 22: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/22.jpg)
Create New Assessment
Select assessment type and click begin
Date and time should reflect actual date and time assessment was performed.
******Documentation choices depend on job title.
![Page 23: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/23.jpg)
Admission Assessment
From this screen document Admission History, Admission assessment, ad other needed assessments, ie, pain/ comfort or restraints.
Selecting ‘Required Assessments’ automatically selects the Admission History, Body Systems, Fall Risk, Pneumonia/Flu, Sepsis Screening and Education. Others may be selected as needed. Each system displays in the order they appear on this screen.
Select chart detail to continue
*****Assessments can only have one time assigned to that assessment. If the LVN does the adm hx, RN who completes the admission must time her assessment at least 1 minute later.
![Page 24: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/24.jpg)
Admission History
Opt Out is a mandatory field.Answering “yes” only indicates thatyou have offered the patient the optionnot whether they want to opt out or not.
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
Adult ICU, PICU and CCH only do Admission History,
![Page 25: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/25.jpg)
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
![Page 26: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/26.jpg)
Admission HistoryNutritional Screening
Selecting any of these will send a consult to Nutrition Services
Not required but useful information
![Page 27: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/27.jpg)
Admission HistoryChaplain Referral
Selecting “chaplain referral” will generate automatic consult
These fields are mandatory.Cannot move forward until completed
![Page 28: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/28.jpg)
Admission HistoryContinuum of Care
Anticipated discharge placement
Selecting any of these will generate a referral
![Page 29: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/29.jpg)
Admission HistoryAdvance Directives
Executed Advanced Directives is a required field
![Page 30: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/30.jpg)
Admission HistoryPast Medical/Surgical History
LVNs may only select “Update Pending”Update Complete will be grayed out
Enter date of vaccination if known,You can check ‘Immunization History” in Navigator bar for immunization date status if unknown. This is S&W info only.
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.
![Page 31: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/31.jpg)
Pneumococcal Screen
Screens are age based:Either > 65 yrs of age or18 – 64 yrs of age
18-64 yr old must have a chronic illness to qualify.Chronic illness box lists example diagnosis
Patients in SWMH ICU are not screened for vaccinations
This question refers to this group or questions only
![Page 32: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/32.jpg)
Flu Screen
Verify that months are within flu season
Verify if flu vaccine already given this flu season.Refer to immunization history in navigator bar.Make sure you update/ pend before opening immunization history as it will kick you out and will lose everything you just entered.
![Page 33: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/33.jpg)
H1N1 ScreenH1N1 to be given until further notice from Administration
Patient must:1. Review H1N1 protocol2. Meet protocol3. Consent to vaccine
If any of these do not occur, patient does not receive vaccine
![Page 34: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/34.jpg)
AssessmentWithin Defined Limits (WDL)
“WDL All” indicates your assessment meets the defined limitsSelect “except for” to document exceptions to WDL.
![Page 35: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/35.jpg)
Assessment Cardiovascular
Most selections can be entered via the point and click method using the radio buttons,Checkboxes and free-text data entry fields
Remember any choice with“…”, additional screens will need to be completed
![Page 36: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/36.jpg)
AssessmentEdema
Click the “Grade” buttonfor definitions
![Page 37: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/37.jpg)
AssessmentBraden Scale
Braden scale must be assessed every shift
Document any skin abnormality on this screen
![Page 38: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/38.jpg)
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
![Page 39: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/39.jpg)
AssessmentFall Risk
You must select either “no fall risk” or one or more of the risk factors listed to proceed.
![Page 40: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/40.jpg)
Fall Risk Interventions Screen
Standard precautions always necessary for a fall risk patient.
Then, choose any other precautions done to protect patient
![Page 41: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/41.jpg)
Initial Restraint Documentation &Every 2 hour CMST Checks
![Page 42: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/42.jpg)
Initial Restraint AssessmentRestraint assessment must be made prior to applying restraints. Document all actions taken prior to application of restraints.This is usually a “focus “note
Family and patient must be informed of reason for restraint usage
![Page 43: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/43.jpg)
Restraint Assessment
Document all alternatives tried and responses to those
![Page 44: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/44.jpg)
Restraint Assessment
Initial CMST (Circulation, Motion, Sensation, Temp) check
RN must assess for continuation of restraints or not
![Page 45: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/45.jpg)
Every 2 hour CMST Checks
Document Restraint data hereChange date/ time as needed to reflect required q 2 hour restraint documentation.
Items clicked yes require description
Document interventions every 2 hours and add comments as needed
Click update complete to store data
![Page 46: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/46.jpg)
Sepsis ScreeningShift and Focus
This is an example of a patient who is septic but not in severe sepsis or in shock.This screen walks you through the process of identifying a patient who is either: 1.septic (has an infection UTI, Pneumonia, wound infection)2.In severe sepsis3.In septic shockThis is done q shift on all units. If a patient’s status changes, can be a focus note.
This identifies that the patient has more than 2 SIRS and a known or suspected infection. The patient has not had a serum lactate greater than 4 or organ failure
![Page 47: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/47.jpg)
Positive Sepsis ScreenThis screen has identified a patient who has gone from severe sepsis to shock.1.The patient had 2 or more SIRS with a suspected or known infection2.A lactate acid or 4 or greater within the last 24 hours3.Patient has not had response to fluid challenge to increase B/P4.Patient has one or more organ failures.
Identification of Severe Sepsis or Septic Shock will trigger the pop up box to notify PCP and call a Dr. Rapid.Make comments in the comment box as to what was done in regards to this patients positive screen.
![Page 48: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/48.jpg)
Assessment Storing Data
Select update/complete or update/pendingto save entered data
Assessments that were visited are underlined. Last chance to go back and address any initial assessment you may have missed.
![Page 49: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/49.jpg)
Shift/Focus AssessmentsAdmission History not an option on this screenRequired assessments include body systems, fall risk and educationOther options, ie, Peripheral IV, Pain/Comfort, etc. may be added as appropriateAll other steps are the same as the admission assessmentSee next slide
![Page 50: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/50.jpg)
Shift/Focus AssessmentsIf 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
![Page 51: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/51.jpg)
View Assessments
Click to view assessment, select assessment,and click view.
![Page 52: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/52.jpg)
View Assessment
This is how data displays when “View Assessments” is selected
![Page 53: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/53.jpg)
Change/Delete Assessment
Select Change/Delete Assessment,the assessment to be changed or deleted, then click the appropriate button for that function.
![Page 54: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/54.jpg)
Change Assessment
Only change your own assessments
![Page 55: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/55.jpg)
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.
![Page 56: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/56.jpg)
Delete Assessment
This is the final screen before you delete an assessmentOnly delete your own assessments.
![Page 57: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/57.jpg)
Guidelines for Delete Assessment
Use Delete when you have charted on the wrong patient. Delete only your own assessments
![Page 58: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/58.jpg)
Complete Pending Assessment
Select “Complete Assessment”, choose assessment in pending status (P), then click complete.
![Page 59: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/59.jpg)
Discharge Assessment
Enter date/time the patient left the unit. Not the time of the discharge order
Click continue to move to next screen
![Page 60: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/60.jpg)
Discharge Assessment
This question asks if immunization status was assessed.
Indicates if administration of vaccine occurred.
Document discharge education, patient response, and pain status at time of discharge
![Page 61: PCD TRAINING MANUAL Licensed Staff](https://reader033.vdocuments.mx/reader033/viewer/2022061608/56816049550346895dcf7143/html5/thumbnails/61.jpg)
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