PowerChart Maternity COLUMNs and ICONs- OB Beds Tab

Transcription

1 PowerChart Maternity COLUMNs and ICONs- OB Beds Tab The tracking shell provides an overview of patient location, status, and workflow. Patient names will display after registration via STAR. The columns of the tracking shell display and sort patient information and activities related to the patient. Not all tabs display the same columns. The Tracking Shell: Will be used in place of the PAL, as a tool to organize the user s workflow Provides users with a quick overview of the patient s overall status 5 different views or tabs-each provides unique information Tabs refresh every minute. Columns can be resized/sorted, but will return to the default when you log back in. Italicized name in the Name column indicates patients with the same last name. Most tabs have filters. Use the filters to get a specific view. A Quick View Default Flowsheet can be displayed by double clicking in most fields beyond the G or gravida column. Patient Indicator and Demographic Columns: Patient Indicator: single click to highlight the patient row or dbl. click to open the patient chart. Bed: patient s room number. VIP: Indicates the patient s publicity code such as Opt Out Only or Restricted Name Patients name

2 Status Status: displays patient s current status. Single click to change status. Age: patient s age. Auto populates from admission. Allergy Column: Allergy information can be entered or modified from this column. Double click in the allergy cell to add, modify, review, or cancel allergies. Allergies have not yet been recorded Patient has allergies recorded. No known allergies. Assigned RN and Provider Displays the name of the nurse or provider caring for the patient. To Assign an RN to a patient: 1. Highlight the appropriate patient. 2. Select from the tool bar. Or right click in the field and select Assign Provider. 3. The nurse s initials and phone number will display from your initial log on information. To Unassign an RN: 1. Highlight the appropriate patient. 2. Select the tool bar. Or right click in the field and select Unassign Provider. 3. The nurse s initials/phone number will no longer display. OB Nurse OB Nurse: indicates nurse caring for patient. Attending: indicates attending provider. EGA Column: EGA: Estimated Gestational Age populates from nursing documentation of the EDD in the Pregnancy Summary. Delivery Status Icon: green checkmark indicates the pt. has delivered. Populates from nursing documentation of the delivery. Hover to view details. Labor Status Gravida/para/dilation/effacement/station/ROM/fluid description: columns will auto populate from nursing documentation.

3 Events The Event Window may be used to request, start, complete, or cancel an event. The To Do, Communication, Rubella, and GBS columns can be managed from the Events Window. To View the Events Window: 1. Right click in any of the following columns: To Do, Communication, Rubella, GBS 2. The Events Window displays To Add an Event: 1. The most common event that would need to be added manually if the patient requests NO VISITORS. 2. To manually add this event, click the No Visitor box and click Apply and OK. To Remove an Event: 1. Click in status column from bottom portion of window, click complete or cancel. 2. Click Apply and OK. Events Window Confirm correct patient. Select No Visitors to display on Tracking Shell. Other listed Events will become activated from documentation. Opens to requested or started events. User name. Type of Event Status of Event Click in Status field and select Complete or Cancel. Click Apply and OK Communication Column: The communication column displays charted patient data gathered on admission, from an order, or may be manually selected from the Events Window. Hover over icon to view.

4 Patient is diabetic Surrogate mother Baby is up for adoption Bottle feeding Breastfeeding Fetal/Neonatal Demise-must be entered manually from tracking shell??????? No visitors-must be entered manually from tracking shell. Right click in communication field. Rubella Column: Rubella Immune Rubella Non-Immune GBS Column (Group Beta Strep): GBS Positive GBS Unknown GBS Negative Activates/Tasks Column: Tasks are nursing actions that must be completed regarding patient care. Tasks populate the tracking shell from a patient admission, orders, or from a system generated rule. The most recent tasks will display at the top of the view. RED tasks indicate past due. Medication Task: hover to view ordered and completed medications; dbl. click to view medication tasks. Medications can be charted as Not Done from the tracking shell. Patient Care Task: hover to view patient care tasks; dbl. click to view patient care tasks. Click desired task to document. Most Maternity tasks will be patient care tasks. Assessment Task: hover to view assessment task; dbl. click to view assessment tasks. Click desired task to document. Other Task: hover to view misc. task; dbl. click to view tasks. Click desired task to document.

5 To Chart Tasks: 1. On Tracking Shell double click on task icon to open task list. 2. Check box for desired task. 3. Click Document button. If a form is attached to the task, the document will open for charting. Complete charting and Sign. Tasks Without Forms Attached: 1. Some tasks are reminders with no attached form. In this case when Document is selected a Chart done window will open. Complete the Chart done details and Sign. Chart Not Done: Used for med tasks, same as Not Given. Removes task from list without charting on the form, used for tasks that have already been completed through Ad Hoc. 1. Check box for desired task. 2. Click Not done button. 3. Click drop down arrow to document reason and Sign. Note: blood and rhogam orders. After the order for a blood product has been entered, nursing will be notified that the blood product is ready from the lab by a Patient Care Task on the Tracking Shell. No blood drop will appear. To communicate to lab to send the blood product, check the box next to the task, click document, Sign the chart done note. Patient Checks Column: Pt. Checks Pt. Checks: displays the last postpartum or newborn assessment documentation as unchanged or changes documented. Hover to view the time of the last assessment to know when the next assessment is due to be completed for mom and/or baby.

6 Nurse Review Column: Nurse Review: indicates there are Orders waiting to be nurse reviewed. Open the patient s chart to the Orders tab to Nurse Review the orders. Staff cannot nurse review the orders from the Tracking Shell. Lab Column: Lab Indicator: 1 st number indicates number of tests ordered, the 2 nd number indicates resulted labs. Hover over column to see which labs have been ordered. Double click on the column to display the Quick Default Flowsheet.