This document will walk a Nurse through all SBAR tasks in SigmaCare, including: Adding a new SBAR from Resident Summary Page 1 Adding a new SBAR from an open Stop and Watch Page 2 SBAR Entry... Page 3 Completing the SBAR.. Page 10 Abandoning the SBAR. Page 10 Printing the SBAR. Page 11 Viewing the INTERACT Audit Log Page 11 Linking the SBAR to a Transfer Event. Page 13 Linking the SBAR to a Discharge Event Page 14 Viewing the SBAR Log. Page 14 Creating an SBAR form from the Resident Summary Step 1. From the Navigation Bar click Select Resident. Step 2. In the Last Name field enter the first few letters of the residents last name. Step 3. Click Search. Step 4. Click on the name of the desired resident. Step 5. Beside the resident name, click the Available Actions icon. Note: An SBAR may be created from anywhere in the system that the Available Actions icon appears OR The SBAR may be created from the INTERACT tab of the resident summary 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 1
Step 6. Click New SBAR Step 7. The SBAR Entry page will open, for data entry. Creating an SBAR form from an open Stop and Watch Step 1. From the Navigation Bar Logs click Stop and Watch Step 2. The Stop and Watch Log will Open. Click the blue arrow in the Actions column to open the menu for the Stop and Watch that you wish to work with 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 2
Step 3. Click Create SBAR. Step 4. The SBAR Entry page will open for data entry. SBAR Entry Step 1. From the SBAR Entry page, you may select a Stop and Watch form from the drop-down to link to the SBAR if one has been completed. 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 3
Step 2. Check the Change in Condition checkbox for all issues that are affecting the resident. Step 3. Enter the date This started on and from the dropdown choose whether the condition has become: Better Worse or Stayed the same Step 4. Enter text to indicate if there are Things that make the condition worse Step 5. Enter text to indicate if there are Things that make the condition better Step 6. Select the appropriate radio button to indicate if This condition, sypmtom, or sign has occurred before. Step 7. Enter text to indicate if there is any Other Relevent Information. Step 8. Select the appropriate radio button to indicate what The resident is in the facility for. 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 4
Step 9. If a primary diagnosis has been indicated on the residents diagnosis list it will prefill the Primary Diagnosis field. To delete the prefilled primary diagnosis, click the red X. To add a diagnosis or to replace a deleted diagnosis, click the desired diagnosis name. Step 10. A complete active diagnosis list will be provided so that you may choose Other Pertinent History. Click the diagnosis description to select it. Step 11. Choose the appropriate radio button to indicate whether there were any Medication changes in the last week. Step 12.Click the checkboxes to indicate any of the medications that the resident is currently using. If you are unsure, click the View Current/Historical Medications link to view the residents medication orders. 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 5
A popup window will display with a list of the residents current medication. The search field may be opened to include historical medications, or medications used within a particular date range. The data shown will include the medication name and SIG, the date and time the medication was last administered, and the diagnosis associated with the medication. Step 13. Allergies will prefill from the residents active allergies. To include all allergies on the SBAR click Select All OR Select individual allergies by clicking on them to add to the SBAR 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 6
Step 14. Enter the resident s Vital Signs. Note: If the resident has current vital signs (within the last 24 hours) they will prefill the SBAR in green print. If any data in a prefilled row needs to be edited, clear the entire row by clicking the clear link at the end of the row. The row will be cleared, in order to provide for entry of updated information. Newly entered data will appear in black type. Note: New vital signs entered and saved into the SBAR will create a new clinical monitoring in SigmaCare. Note: Data entered with a new method (for example a blood pressure taken while lying) will not replace the sitting blood pressure in the clinical monitoring section it will simply be added as another current clinical monitoring item. When the current method is sitting (as above) and a new sitting blood pressure is entered that entry will replace the previously entered sitting blood pressure and become the new current clinical monitoring for sitting blood pressure. 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 7
Step 15. Check any appropriate checkbox for Mental Status Changes. Note: When checkboxes are checked throughout the SBAR, additional information may be requested (as noted by the radio buttons above). Note: When an indicated checkbox creates a notification regarding contacting the physician a View Notification link will appear next to the resident s photo this link will always appear in red.in addition, the line that triggered the notification. display a red View Notification message indicates that the physician should be contacted immediately, a blue View Notification link indicates that the notification is non-immediate. Click the link to view the notifications (notifications may be viewed when the entire SBAR is completed or at any time during entry). Note: When notifications are viewed, they will indicate the urgency associated with them. This urgency indicates the need to call the physician. Please refer to facility policy as the urgency indicated is only a recommendation based on the responses within the SBAR. Below is a sample based on the responses above: Step 16. Use the textbox to Describe changes in mental status. Step 17. Check any appropriate checkboxes for the Functional Status Evaluation. 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 8
Step 18. Check any appropriate checkboxes for the Behavioral Evaluation. Step 19. Check any appropriate checkboxes for the Respiratory Evaluation. Step 20. Check any appropriate checkboxes for the Cardiovascular Evaluation. Step 21. Check any appropriate checkboxes for the Abdonimal Pain/GI Evaluation. 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 9
Step 22. Check any appropriate checkboxes for the GU/Urine Evaluation. Step 23. Check any appropriate checkboxes for the Skin Evaluation. Step 24. Check any appropriate checkboxes and radio buttons for the Pain Evaluation. Step 25. Check any appropriate checkboxes for the Neurological Evaluation. Step 26. Check any appropriate checkboxes for the Advanced Care Planning Information. Step 27. Use the textbox to Summarize your observations and evaluation. 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 10
Step 28. The residents primary physician will be prefilled. Use the drop-down, if necessary, to edit which Primary Care Clinician Notified. Enter the date and time the clinician was Notified On and, in the textbox enter any Recommendations of Primary Clinician Step 29. Following the conversation with the primary care clinician, review the checkboxes and Check any that apply Step 30. Enter the Name of Family/Health Care Agent Notified, and the date and time they were Notified on. Step 31. Click Save Note: Upon saving any notifications triggered will be displayed. Completing the SBAR After the information contained within the SBAR has been communicated with the physician and a plan of care has been established the SBAR may be completed Step 1. From the top of the SBAR Entry page click Complete SBAR Step 2. In the SBAR information box the status will change to completed. 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 11
Note: Once Completed the actions available will change and the SBAR may be re-opened if needed. Abandoning the SBAR When an SBAR has been created in error, the SBAR may be abandoned. Step 1. From the top of the SBAR Entry page click Abandon SBAR. Step 2. In the SBAR information box the status will change to abandoned. Note: Once Abandoned the actions available will change and the SBAR may be re-opened, if needed. Note: When an SBAR is abandoned any associated Stop and Watch forms will be returned to an open status, as the disposition will no longer be determined. Printing the SBAR Step 1. From the top of the SBAR Entry page click Print SBAR. Step 2. The PDF version of the SBAR Communication Form will open. In the top right corner click the Printer icon. 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 12
Step 3. From the available printers, select the printer that you wish to print to. Step 4. Click Print. Viewing the INTERACT Audit Log Step 1. From the SBAR Entery Page, click View Audit. Note: The INTERACT Audit Log will open, with a list of events, showing the date time and the user who completed the event. In addition, from the Actions menu you have the ability to view the audit event, and to view the SBAR. 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 13
Step 2. From the Actions menu, click View, to view the details of the audit event. Linking the SBAR to a Transfer Event Step 1. From the Transfer Resident page, choose the desired SBAR from the SBAR drop-down. When all information is entered, click Save. Note: Once selected, the Print SBAR? checkbox will check by default. If you do not wish to print the SBAR, click the checkbox to remove the checkmark. 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 14
Linking the SBAR to a Discharge Event Step 1. From the Discharge Resident page, choose the desired SBAR from the SBAR drop-down. When all information is entered, click Save. Note: Once selected, the Print SBAR? checkbox will check by default. If you do not wish to print the SBAR, click the checkbox to remove the checkmark. Note: Once linked to the discharge the SBAR will be availlable on the Resident ADT information page. Viewing the SBAR Log Step 1. From the Navigation Bar Logs, click SBAR. 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 15
Step 2. The SBAR Log will open, showing all In Progress SBAR s. From the Actions menu you can: View This will open the SBAR for continued data entry or review. Complete Mark the SBAR Completed and remove it from the list Abandon Mark the SBAR Abandoned and remove it from the list Print Allows printing of the SBAR Step 3. To view Abandon or Completed SBAR forms, expand the search field by clicking + Search Fields. Step 4. Enter the desired search criteria. Step 5. Click Search 2016 ehealth Solutions, Inc. All Rights Reserved, For Licensed SigmaCare Users Only Page 16