SCM Clinical Documentation Manual.pdf - Saskatoon Health ...

SCM User Manual 18

Clinical Documentation

Section: General – Documenting in SCM – Basics

When to Document on Paper and When to Document Electronically

If your patient is unstable and documenting electronically will compromise patient safety you

CAN document on paper until the patient is stable or it is safe for the patient to convert to

electronic charting. Cardiac arrests, Level 1 Traumas, Stroke Alerts, and CTAS 1 patients will be

documented on paper.

Process for converting from Paper to Electronic

In your progress notes section on paper write see electronic documentation for further

charting. Ensure you document the date and time on your note

In your progress note section on your electronic document add a single time column and type

see paper charting for previous assessment

Process for converting from Electronic to Paper (Code Blue, Conscious Sedation)

In your progress notes section add a single time column and document refer to paper

documentation (specify Code Blue record or Conscious Sedation, if applicable)

Once you are ready to convert back to electronic charting enter a progress note for that time

and document Conscious Sedation completed refer to electronic charting for future charting

Opening a New Document

Opening a NEW Document:

1. Select your patient and click on the Enter Document icon

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2. The Document Entry Worksheet will open. You can search for the document one of two

ways:

a. Manual Entry allows you to find your document if you know the name of it

i. Type the document name in the search field

ii. The document name, ALC in this example, will appear under Document Name –

double-click to open the document

b. Start of Browse Menu is a navigation tree that allows you to narrow down your

document search without needing to know the exact name of it

i. Select Start of Browse located in the drop-down menu on the left hand side of

the Document Entry Worksheet.

ii. You will see the following options and will need to select one to further narrow

down your document search. These options are expanded by selecting the

beside the area you wish to open

iii. You will then need to select one of the subitems. Once you do this it will bring up

the documents associated with that area and care provider type

iv. Select the document you want to open located under Document name and then

click on Open


Creating your Personal Document Preferences

By creating your Personal Document preferences, the documents that you utilize will

automatically display when searching for your documents


To create your Personal Documents:

1. Click on Preferences in the Taskbar and then select Document Entry. The Personal

Document Entry window opens

2. Under All Documents, click on the + button in front of the type of department that you

work under. This will open a list of roles that can include Nursing, Physician,

Interprofessional Practice, and MOA

3. Click on the + button in front of your role. A list of documents appears

4. Click on one of the documents that you will use – it will become highlighted blue

5. Click Add. That document now appears in the Selected box

6. Repeat steps 4 and 5 to add all the documents that you will use


7. Click Close

Navigating through the Document

The structured note document will open in its entirety so that you can scroll through the entire

document to certain sections for data entry

As an alternative, you may use the Navigation Panel to locate specific sections of the

document:

Pinning the Navigation Tree

1. At the left side of the document, click on the Sections tab to open the navigation tree

2. Click on the pin to lock the Navigation Panel in place. You may need to make the

navigation tree wider by hovering between the navigation tree border and the

document border until the widening arrow icon on the mouse appears. Drag the mouse

to the right until you can see the navigation tree fully

3. Select the section of the document for data entry


Navigation Tree (Sections)

The navigation panel on the left side of the screen shows all the major headings in the current

structured note

• Note the headings with asterisks (**) and that are in bold

• Sections with asterisks contain information that has come from a different note

and will be included as documented by you in your note, so this information

needs to be validated by you with the patient before finalizing the note

• Bold items contain the information that has flowed in but has not been saved

yet, it is a visual reminder to check the area for the information that needs to be

validated


• Always check the navigation tree before saving to make sure that no new

information has flowed in needing validation (Bold and/or new **). For example,

if a physician and RN are documenting at the same time, information may flow

from one document to another and needs to be checked by the other person

before saving. As we know, the bedside nurse often gets a different story from

the patient than the Triage nurse, and this story is also often different than what

the physician gets

• Documentation in the electronic world is much more fluid than on paper and

requires a slightly different workflow

• Prior to electronic documentation you never had to worry about what

someone else would add to your document before you started or before it

was finished and signed!

• Each section may be accessed directly by clicking on the heading to open the section

tree and also the first page in that section, and subsequent pages may be accessed

either directly from the tree or by clicking on the navigation arrows to step through each

section in order

Preview Tab

The Preview tab will open a preview window allowing you to review your final document before

saving it


How to Change Date of Service

Note: Changing Date of Service can ONLY be done when charting on a NEW document. Once a

document is saved, Date of Service cannot be changed.

Open a NEW Document

1. Select your patient and click on the Enter Document icon

2. The Document Entry Worksheet will open. Change Date of Service if different from the

defaulted date of today’s date

3. Enter name of document in the search field

4. A list of document(s) matching the search query will appear – double-click to open the

document

You can also change the Date of Service within a document at the top of the document as seen

below.


Adding a Cosigner

Physicians

As a “LEARNER”, a CO-SIGNATURE IS REQUIRED for the patient to show up on the Attendings

Patient List. As a “LEARNER”, you will be able to save Documents only as “Incomplete”. A

checkbox is available on the top of the “Enter Document” icon, check the “Co-signer” box and

ensure your supervising physician is listed as the provider. Alternatively, you are able to check

the Co-signer box on the left sided “Sections” navigation pane, as below (make sure the Care

Provider is your supervising physician)

Other Care Providers

Students can enter notes which will be cosigned by their preceptor

After opening the electronic document, click on the Document Info Tab (left hand side of document)

Click in the box under Co-Signer(s)


The Co-Signature window opens > select Other > enter in the preceptor’s name > select Search > select the correct person from the list > select OK

Create the document

Click Save. A pop-up message will appear indicating that students will not have the right to save the note as complete


Click Submit as Incomplete

The Reauthentication Window will appear > enter your password

In the Documents Tab, the signature status of the note will appear as ‘Signed w/ additional Signatures Pending’

The preceptor will be responsible for modifying the document (if required) and saving the note as complete

It is recommended that preceptors have the To Sign and Incomplete Document columns added to their patient list in order to keep track of student documentation

o Select the Visit List Column icon

o From the Available Columns list, select desired column

o Click Add

o You may sort the order of the column by selecting a column and clicking the Move Up or Move Down buttons

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Components of the Document

A. Structured Note Toolbar

Copy Forward

Allows you to copy information from a previous note. You can copy forward an entire document or sections of a document from a previous note or visit using the Copy Forward button located at the top of the new document that you have opened. This option will only work for the same observation

Click on the Copy Forward button. The Copy Forward Information from Previous Note window opens

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1. Under Documents – Click on the document you wish to copy 2. Select the sections you want to copy forward to the new note by clicking in the

squares in front of each section 3. Select Copy Items Into Current Note 4. Information would require validation and changes made as required

Refer to Note

Allows you to refer to information in another note without reassessing it. Refer to Note will pull

the information from another note with a reference attached to it


Click on the Refer to Note button. The Refer to Note Information From Previous Note window

will open

1. Under Documents – Click on the document you wish to copy 2. Select the sections you want to refer to in the new note by clicking in the squares in

front of each section 3. Select Reference Items in Note

Preview

The Preview Button will open a preview window allowing you to review your final document

before saving it. The preview pane can be displayed on the right side or on the bottom of the


Structured Notes Entry worksheet depending on which option you select in the Preview drop-

down menu

**Please note that using the preview option will slow down responsiveness of documentation

during charting**

Modify Template

Opens the Modify Template menu. This menu allows you to modify the template of your

document and from here you can add or delete sections of the document

1. In the Structured Notes Entry window, click Modify Template. The Modify Template

window opens

2. Select the check boxes next to the sections you want to add. Deselect an item to remove

it from the note

3. To save the template, do one of the following:

a. To use the template for all the patients on your patient list, select Save Template for

Me

b. To use the template for the current patient record, select Save Template for Patient

Navigation Buttons


The First button brings you to the first heading at the very beginning of the navigation tree in

the document whereas the Last button will bring you to the last heading in the navigation tree

at the very end of the document. The Previous button will bring you to the previous heading in

the navigation tree and the Next button will bring you to the next heading in the navigation

tree

B. Date and Time Fields

Date fields are set-up to display as day-month-year and can be entered 4 different ways (time

fields use the 24-hour clock):

Typed manually, by clicking on the dd field, MMM field and then the yyyy field

Chosen on a calendar by clicking on the C

Entered for previous days, by clicking on the T, typing “T-1” and clicking Enter to enter

the date the day before, or typing “T-#” and clicking Enter with # being the number of

previous days you are entering

Entered for the current date and time by clicking on the

Please Note: The above options allow you to back-date

C. Single Select and Multi-Select Buttons

Round buttons only allow one choice while the square buttons allow one or more

choices

When wanting to deselect a single select item, right-click on the item and select Delete Data

from the menu that appears:

Multi-select buttons can be unselected


D. Free Text Fields

Sections of the document may have free text fields, areas of white space, that allow you to type

in whatever you want to document

Use acronym expansion to speed up your documentation in the free text fields. Please see the Acronym Expansion section of the manual for a more detailed explanation

Please do not use the following special characters, &, /, ~, ^, when entering information into

the free text fields

E. Drop-Down Menus

Drop-down menus allow users to select from predetermined options within a list by selecting

the button as seen below


F. Ellipsis

Three dots (…) called ellipsis after a field name indicates that more data fields are hidden

(when this field is selected, more fields related to this question will be revealed right under the

selected field)

G. Mandatory Field

The icon indicates that the observation is a Mandatory Field, and the clinical document cannot be saved until charting in this section is completed

Once an item is selected, a pop-up window appears reminding you to select and enter necessary fields in the Patient Designated ALC & Waiting for… section, which is located just above the last section on the note called Discharge Status


H. Incomplete Icon

The icon indicates that an observation is significant. The clinical document will be saved as Incomplete until an item in this Significant Field is selected. This rule is just a reminder to enter data into this section when necessary. The document saving as incomplete is not an issue

I. Autocalculation

Some documents may contain a section that will autocalculate a measurement or score based on entered in values. In the example below the BMI is autocalculated when the patient’s height and weight are entered in the appropriate sections

J. Add Item Button

Within documents you can perform certain functions by using the Add Item buttons as seen

below

This is the Adding New Care Providers button. When you select this button it opens the

Care Providers (Adding New) menu. From here you can add care providers. Please see How to


Add or Update a Care Provider (Physicians) in the manual on adding new care providers.

This is the Adding Significant Events button. When you select this button it opens the

Significant Event (Adding New) menu. From here you can add in significant events to a patient’s

chart. Please see Entering a Significant Event in this manual for more detailed information on

how to add a significant events

This is the Adding Health Issues button. When you select this button it opens Health Issues

Manager. From Health Issues Manager you can add in Health Issues to a patient’s record.

Please see the Health Issues Manager portion of the manual for more detailed information on

Health Issues

This is the Refresh button. This button manually refreshes your screen and it allows you to

see the latest data that has been entered on your patient

This is the Restore Original Sort button. Right now it is not currently being used

K. Body Images

Some documents, like the ED Nurse Admission document, allow you to insert body image templates that you can modify to visually depict assessments. The standard defaults for the images are Adult Whole Body Front/Back and Adult Whole Body Side and Pediatric Front and Back


To modify an image click on the desired template to open the Image Annotation Dialog window that allows you to draw what you want to depict

The pen button allows you to draw on the image

The brush button allows you to draw thicker lines on the image

The eraser button allows you to click on the area of the image that you wish to erase

The undo button will undo the work that you last created

The delete button will delete all of the work that you created

This menu allows you to adjust your pen sizes, pen colours and eraser sizes by selecting what you want from the drop-down menus

When you have completed the drawing in the Image Annotation Dialog window, click OK and it will now be viewable in your document


Image Comments

You can free text any comments that you want to make regarding your image in the Image Comments section under the image. See the example below


Modifying Body Image Templates

To add or delete body image templates Click on Modify Template

The Modify Template menu will open. This menu allows you to modify the template of your

document, and from here you can add or delete the images by scrolling down to the Body

Images section or by typing body images in the search window

Once you are in the body images section you can click on a check mark to remove a selected

image type or click in an empty box to add an image type. In the example below PEDIATRIC is

deselected and Eye is selected


This is what the body images in the document will now look like with the template changes

Acronym Expansion

Acronym Expansion is a shortcut tool in SCM that allows users to enter in an acronym that is

then expanded out into words and/or sentences. In order to utilize this function the acronyms


must first be created within SCM and mapped to specific words or sentences. It is used for

commonly entered in phrases and words

Creating New Acronyms

When creating a new acronymn note that the acronyms are case senstive. If you set up an

acronym that is capitalized you have to type it in everytime with the capitalization for it to

work. If you do not, the acronym will not expand.

On the toolbar choose Preferences and Acronym Expansion

When the Acronym Expansion Maintenance Dialog box opens, choose Add

When the Acronym Expansion-Add\Edit\View\Dialog menu opens, type in the acronym you

wish to use under the Acronym box with a period in front of it. Note that when adding an

acronym, in the Acronym box, enter the acronym but do not use the following characters


except as the first character “.” (period), “?” (question mark), “:”(colon), “;” (semicolon), “,”

(comma) and “!” (exclamation mark). The aforementioned characters are called acronym

terminators, which are reserved characters you enter to open the acronym search pop-up

window. For example, .wbc is an example of a valid acronym whereas w.b.c. is not

Next, enter in the text you wish to see in the Expanded Text area. When you are done select

OK, or Apply if you want to add more than one acronym. The maximum amount of characters is

20,000. However, application performance might degrade if you use lengthy expanded text.

In any free text area on a structured note or flowsheet, type in the acronym. Remember to use

the period at the beginning of your acronym that you wish to expand

Press Enter or the space bar and the Expanded Text will appear


Importing Acronyms from other users

You can also import acronyms from other users instead of creating your own acronyms.

On the toolbar, choose Preferences and Acronym Expansion…

When the Acronym Expansion Maintenance Dialog box opens, choose Import From Other User.


The Import Dialog menu will open. Go to the drop-down list Select From Existing list to select a

care provider’s premade acronym list. The list is organized alphabetically by care provider’s

name. Click on a care provider that you wish to borrow acronyms from. Once selected, that

care provider’s acronyms will be displayed and you can select the acronyms you wish to borrow

by clicking in the empty box next to the acronyms that you want. In the example below, .behl

and .ecg are selected. Once the acronyms are selected click OK

Editing Imported Acronyms from other users

Once you have imported Acronyms from other users you have the ability to edit the expanded

text portion of the created acronym. You cannot edit the acronym created by the user

Select the acronym you wish to edit, .ecg in the example below, and click on Edit


Overwrite the current expanded text with what you wish to see. In this example, “ECG

technician in to perform 12 lead heart tracing” replaces “ECG complete”. Click the OK button

when you are satisfied

Renewing the Length of Time for Data Entry

When you open a document for charting, you are “locking” that document for data entry by yourself - another user has read-only access to the document until you save the document


After 10 minutes of data entry or inactivity in an electronic document, you will receive a pop-up message asking you to renew your time in the document for another 15 minutes

When you do not renew your time on the document, you risk another user opening the document, charting and saving the document without you saving your data entry. You will not be able to save your charting You will need to copy and paste your free text information into a Word document, exit the document, re-open the document to copy your information into the document and complete your data entry

How to Save your Document as Incomplete

To save the document as incomplete, you can either:

1. Select Incomplete at the bottom of the document


Or…

2. Click Save and the following pop-up message will appear. Click on Submit as Incomplete

How to Save your Document as Complete

To save the document as complete, please remember to complete the note - select yes

A Reauthentication Window will appear – enter your password


Editing a Document

On the Documents Tab, highlight the document you want to Edit, right-click and choose Modify

Document. This will open the document and you can make the necessary changes

After saving the Document you edited, you will see the icon that shows the document has been

revised

Appending a Document

**Purpose: To add information to chart once note has been completed and patient has left

department.**


If patient is no longer in the department, you may have to search for the patient. (See

instructions below)

1. Go to Documents tab

2. Click once on the note you want to add/change information on

3. Click on the Append icon in the tab toolbar or right-click and choose “Append

Document”

4. A note similar to this will appear and you can enter and save your information

5. Addendum Note will appear on summary of structured note with date and time entered


Viewing Corrections

Open the document and then click on the Corrections tab. The document will display all items

that have been changed in RED. A red C will appear after information that has been added to

the document where none existed before the last save

Cancelling a Document

If you have entered a document in error, i.e. on the wrong patient, you may need to cancel it.

Highlight the document, right-click on the document and choose Cancel Document


You will be asked for a reason and in the drop-down “Entered on Wrong Patient” can be

chosen. Other reasons may be entered as free text

Note that once the document has been cancelled you will see the icon that shows the

document has been cancelled

Viewing Document Status

Highlight the document, right-click and choose View Status History


The Status History shows Who modified the document, the Status at that time, and the Revision

Status

Health Issues Manager

The Health Issues Manager is a module in SCM designed to maintain an up-to-date list of

current and active Health Issues for the patient. The Health Issues list serves as a centralized

problem list for clinicians to document and reference a list of diagnoses or conditions that the

patient currently has or has experienced

Accessing Health Issue Manager

You can access Health Issues Manager one of three ways:

1. Clicking on the Health Issues icon in the main toolbar


2. Clicking on Health Issues found under the Data Entry section of the Patient Info tab

3. Clicking on the red caduceus icon within a document

Entering a Health Issue

When the Health Issues Manager opens, you will need to search and select the Health Issue

that you wish to add to your patient’s Medical History

Adding Medical Hx, Admitting Dx, Discharge Dx, Secondary Dx

1. Go to the Add New Health Issue section of the Health Issues manager at the bottom of

the Health Issues Manager page


2. Select the type of Health Issue you wish to add (e.g. Medical Hx) under Select a Type

3. Select the Full Catalog Search tab:

a. Type the name of the health condition in the free text box

b. A drop-down box will open under what was typed. From this drop-down you can

select a more specific Health Issue, if it applies, but it is not necessary

c. Click the search button

d. Highlight the correct Health Issue and click on the Add Details button if a

Description needs to be entered, or simply click on the Add button

e. The chosen Health Issue will then be added under the Health Issues tab in the

window above Add New Health Issue

f. Click the Close button once you are done adding in Health Issues

Adding Surgical History

The Surgical History is free text only. You cannot do a search for the specific surgery


1. Go to the Add New Health Issue section of the Health Issues Manager at the bottom of

the Health Issues Manager page

2. Select Surgical Hx under Select a Type

3. Once selected, the Health Issue Details menu opens where the Surgical History item can

be free texted in the mandatory free-text field denoted with the next to Health Issue

4. The date can be entered by first selecting the M/Y selection box and typing in the first

three letters of the month followed by the four numbers for the year (e.g. Aug 1992). If

the date is within a reasonable window, you can also select the Calendar Icon and use

up and down arrows to choose your date


5. Once the surgical history and date have been entered, select Save Changes and the

window will automatically close. If you choose to enter another surgical history item,

then select Apply

6. You will be taken to the Health Issues Manager window where you can see the added

surgical history. Select Close when you’ve finished reviewing

Adding Details to your Health Issue

You can add in more detailed information, such as the onset date, of the selected Health Issue

by clicking the Add details button next to your searched for health issue in the Add New

Health Issue section of Health Issue Manager


Once the Add details button is selected, the Health Issue Details menu will open. Within this

menu, you can free text in a more detailed description of the Health Issue

You can also enter in the Onset Date of the Health Issue by first selecting the M/Y selection box

and typing in the first three letters of the month followed by the four numbers for the year

(e.g. Aug 1992). If the date is within a reasonable window, you can also select the Calendar Icon

and use up and down arrows to choose your specific date

Adding a Health Issue to Favorites

Follow steps 1-3c from the Entering a Health Issue section of the manual. Select the Health

Issue you would like to add and click on Add to Favorites on the right hand screen of the Add

New Health Issue section

The Favorite Health Issues menu will open. From the Favorite Health Issues menu you can

create a category for the Health Issue to be organized in or you can select OK and the Health

Issue will be saved under the <No category> heading


Creating Categories for Health Issues Favorites:

Creating categories for your favourite health issues enables you to organize the health issues

allowing you to find them easier when you search for them

Once you have selected the health issue and clicked on Add to Favorites the Favorite Health

Issues menu will open. From this menu, click on Create Category


A folder labeled New Category (highlighted in blue) will appear under My Favorites. Type in the

name you want to call your New Category folder. When completed, click on OK

Within the Add New Health Issue section of Health Issue Manager under the Favorites tab, the

newly created category and Health Issue will populate

Importing another Clinician’s Favorite Health Issues

1. Click on Health Issues… under the Preferences drop-down menu in SCM Viewer window

2. In the Health Issues Option window, click on Copy From…


3. Type in the Clinician’s name that you are copying from 4. Highlight the correct Clinician under Name 5. Click OK button

6. Click on Copy All, or highlight the favourite Health Issues you would like to copy from the selected Clinician under Favorites for e.g. Behl, Vern and click on Copy Selected. The chosen favourites will appear under My Favorites

7. Click OK button


Adding a Health Issue from Favorites

1. From the Health Issues Manager window, select the Favorites tab. You will now see all

of your listed favourites

2. Select the Add button next to the Health Issue you wish to add to your patient

3. It will then add the favourite health issue to the Medical History List

Discontinuing a Health Issue

If a patient has a listed Health Issue that is no longer applicable (i.e. their hypertension has now resolved), you can discontinue this Health Issue:

In the Patient Tab, ensure you are in the Health Issues Summary View

1. Locate the health issue you wish to discontinue and double-click. This will open the

Health Issue Manager

2. Select Discontinue on the top left-hand corner of Health Issues Manager and the health

issue you have chosen will drop-off your Medical History list


3. To see all discontinued or deleted Health Issues, select Clear All Filters

4. You should now see the struckthrough Health Issue (as seen below):

Reinstating a Health Issue

If a discontinued Health Issue needs to be reinstated (i.e. a once normalized hypertension has

returned), we can Re-activate this by:

1. Opening the Health Issues Manager; ensuring all filters are cleared by selecting the

Clear All Filters icon


2. Select the struckthrough health issue and select Re-activate

3. You will see an H next to the re-activated health issue, and if double-clicked, it will open

the Modification History window and show the changes made, by whom and when, to

the Health Issue


Deleting Incorrectly Entered Health Issues

*** The only time a Health Issue will be deleted, is when it has been entered in ERROR

1. In the Health Issues Manager window, highlight the incorrectly added (duplicate) health

issue. Select the Delete button at the top of the header

2. The now deleted Health Issue will appear struckthrough (when filter is off) and will by

default have a message saying “Cancelled/Entered in Error…”

3. You will see an H next to the reactivated Health issue, and if double-clicked, it will open

the Modification History window and show the changes made, by whom and when, to

the Health Issue


Significant Events

Significant Events are any events that could affect a patient’s treatment or recovery such as

frequent prescription requests, being potentially violent, language barriers, fall risks, etc.

Entering a Significant Event

1. In the Patient Info tab, locate the Data entry section and select Significant Event – this

will open the Significant Event (Adding New) window

2. Select Type of event from the drop-down menu


3. After Type is chosen, the user will then select the Event. Each Type has different Events

4. Enter the Date using either the M/Y section or the Full Date drop-down menu. You may

enter in comments in the free text Description section

l


5. If another Signficant Event is to be entered, select Apply and repeat steps 1-4. However,

if finished entering in Significant Events, select OK

Flowsheet Charting

The flowsheets in SCM are for documenting clinical assessments, interventions, vital signs, and

fluid balances. Currently, they are only used by Emergency Department staff. The four

flowsheets are:

1. ED Assessment and Care

2. ED Triage Reassessment

3. ED Vital Signs

4. Intake and Output

Adding Time Columns

In order to document in the Flowsheets you need to add a time column. The time column can

be added in one of two ways:

1. Select the Add Time Column Options in the tab toolbar

2. Right-click anywhere on the flowsheet and select either Add Multiple Time Columns or

Add Single Time Column


Time columns can be generated from the time of registration of this visit and up to one

hour into the future

Adding Text Label to Time Column

The time columns of flowsheets can be labelled. Columns may be labelled to tie the

observations to medical interventions, like the administration of IV narcotics. To perform this

function, right-click in the top of column after a new time column has been created and select

Edit Text

Enter the intervention into the free text box. The data entered will appear at the top of the

column under the date and time


Documenting in Flowsheets

Once a time column has been generated, you can document in the fields. The fields of the

flowsheet are in rows with a row heading. Each row will open by left-clicking your mouse in the

blue row. This works for the flowsheets beginning with ‘ED.’

Adding Parameters

The treatments and observations that are not frequently utilized are housed within the ‘Add a

Parameter’ function. This functionality keeps the flowsheets manageable by having large

amounts of infrequently used observations and interventions in the background. To open it,

right-click on the flowsheet and select Add Parameter

This will open the menu for the user to find the parameter they wish to add


ED Assessment and Care

The ED Assessment and Care (EDAC) flowsheet is used for documenting the systems

assessments of the patient and any interventions that are carried out. It is an expansive

flowsheet that has the ability to document most all observations of the physical assessment

and interventions performed

The Assessment sections of EDAC begin with a Within Normal Limits (WNL) statement. This

follows the process of charting by exception. If the WNL statement is not fully in context, the

documentor can hover over the blue arrow on the left side of the cell. This will open the

statement making it easier to read

To document in the section, read the WNL statement. If the statement applies, click next to it

in the newly created time column. The assessment window will open. Choose the single-select

radio button by WNL, then OK and then move onto the next cell


If the WNL statement does not apply, click next to it in the newly created time column. Choose

WNL except, and in the next cell identify which observations are variances from the WNL

statement. Avoid double charting by moving to the next cell, if the WNL statement applies


ED Triage Reassessment and ED Vital Signs

These two flowsheets are similar in their design and use. The ED Triage Reassessment is only

utilized when the patient is in the Emergency Department waiting rooms. Values are entered in

the appropriate fields after creating a new time column. After a value is entered, the flowsheet

will take you to the next cell to gain more information about the observation. If you do not

have information to document in a field, go to the next area that you need to document in

How to find Progress Notes Section

Note: To find the nursing progress notes, open the Vital Signs Flowsheet, go to Nursing

Information section and you will find Progress Notes. Add a single time column and free text

your progress note

Intake and Output Flowsheet

The Intake and Output flowsheet (IOFS) is used to track cumulative totals during care. This

flowsheet also has Add Parameter content so that multiple observations can be specified and

tracked. The flowsheet has observations that are premade and present on all flowsheets


Data entry occurs after the addition of a time column. The IOFS maintains cumulative totals for

both the shift and daily volumes. Every entry onto the IOFS Flowsheet will update the totals

automatically.

Labeling IV lines Within an Intake and Output Flowsheet

1. Right-click on fluid you are wanting to label with a specific line

2. Click Modify Row Label


3. The Modify Parameter menu will show up. Fill in the corresponding boxes (e.g. #18 R

forearm under “Site”)

4. Your row is now labeled

**Each Intravenous Fluid row represents a different IV site running that fluid, not

additional bags initiated on the same line**


Hanging a New Bag on an IV line

1. Right-click on specific time column when you are hanging your bag, click on Enter Bag

Details

2. Type in bag number and total volume in that bag and click OK


3. Your row now has Bag Details

Documenting Intake

Document the intake on the appropriate row (e.g. Sodium Chloride 0.9%) by clicking in the

newly created time column and typing in the amount that has been absorbed


Documenting Output

Document the output on the appropriate row (e.g. Catheter, Indwelling Urethral) by clicking in

the newly created time column and enter the appropriate volume of output

Documenting IV Rate Change

1. Right-click on the specific IV type that you want to change the rate of

2. Select Modify Row Label

3. Change the IV rate to what you need it to be under Rate


4. You can see the rate change history by right-clicking on the specific time column and IV

type that you changed the rate of and selecting Show History

5. You will see rate changes as highlighted in the red box


How to Discontinue Running Fluid on an IV Line

1. Right-click on the specified fluid to be discontinued

2. Click Discontinue

3. You will see the row heading is greyed out and new time boxes will also be greyed out

IV Insertion

1. Click on Flowsheet tab and select ED Assessment and Care

2. Select Access Devices, then select Peripheral IV # 1 if it is your first IV to be documented.

If there are more than two peripheral devices, you will need to add the additional IV

lines to document on using the Add Parameter function


3. If procedure done by physician, document ‘Inserted by Dr.(name)’ in the free text box

4. Label the IV by right-clicking on Modify Row Label


5. Document the IV on the Intake and Output for fluid administration

Letters Icon

The Letters Icon allows you to create and save patient letters and referrals

Adding the Letters Icon to the Main Toolbar

If you do not have the icon on your main toolbar, you will need to add it. Follow the steps

below


1. Click on Preferences, then select Toolbar… to open the Customize Toolbar menu

2. To add the Letters button, select the item from Available Buttons and click the

button


3. This will move the button into the Selected Layout. Click on OK

4. Your main toolbar will look similar to this with the Letters icon now added

Using the Letters Icon

To access, create and save/print the patient letters (handouts) and referrals, you will:

1. Select your patient

2. Click on the Letters icon

3. Select your template from the drop-down list for Choose Template Category

4. Select the letter, referral or discharge instructions from the drop-down list for Choose

Letter Template


5. The patient’s name, date and medical records number (MRN) is autopopulated.

Information will need to be entered on the letter or referral anywhere you see [enter

name], [enter X here], [enter number], [enter Pathway Dates here], [enter reason for

referral], etc.

This application functions similar to a Word document - you will highlight the selection

with your mouse and begin to enter in the data. If you do not want the information

bolded, you can choose to deselect this option. Other options (i.e. italic, underline, etc.)

are also available

6. When the data entry is complete, please recheck the information! You can edit

information after you save and/or print but before you exit from the application. You

cannot modify the letter or referral once it is saved on the Documents Tab – it does not

function like other documents

7. Click Save. The Letter Name will be highlighted blue with the patient’s name and date

autopopulated


8. Change the name to the actual name of the letter or referral. Click OK

9. Click Print. Your printer will default. Click OK

10. When completing multiple letters or referrals, select the next letter or referral from the

drop-down list for Choose Letter Template and proceed with steps 4-9

11. If you are done saving and printing your letter(s) and/or referral(s), click Exit


12. The letters or referrals are saved under the Documents Tab. Click on the Display View

icon and select Letters. The letters will display in the field below. Double-click to open

the letter or referral

Status Board

The Status Board is a visual communication tool utilized by all disciplines illustrating the real time status of patients on a clinical unit. Health care providers (HCP) can view current and past information on patients regarding care providers, previous hospitalizations, dictated, electronic and scanned documentation, regional lab and radiology results, current orders, planned discharge date and much more

Changing Status Board Views

“Department” – drop-down list according to which hospital and department you are working in

(e.g. RUH 6000, SPH 7M, SCH Emergency Department). You will only be able to open the status

boards that you have the security rights to.

“View” – drop-down list that is sorted to the particular area you are working in e.g. ERC, Active,

Trauma, Children’s Area, etc.


Common Status Board Columns

Columns Functionality

Location Current location of the patient

STS (Bed) Readiness status of the unoccupied bed

Status updates to dirty when patient is discharged

STS (Patient)

Drop-down list of options:

Admitted (ADM)

Pending Discharge (PD)

Pending Transfer (TX)

Consult Pending (C2C)

Discharged (DC)

ADM - default status when the patient is registered

PD – when selected, the cell will flash green

TX – when selected, the BC4 Timer starts. Use for transfers to Pediatrics

C2C– when Consult Service is selected, the status will change to C2C

DC – when selected, the Remove Patient window will appear. Select Yes to remove the patient to the Inactive Patients View. The patient will be discharged by the Patient Placement Clerks in the Acute Care Access Services (ACAS) Department

Patient Patient name with color-coded background for genders (i.e. blue – male, pink- female)

When the patient has a confidential status, the cell will be blank with the confidential person icon:

Confidential Status will also appear in the blue Patient Header:


Age Pediatric patients will have age denoted in years and months up to age

10

Isolation Alert

Drop-down list of options that match the colour-coding system for the SHA Isolation Alerts

When an isolation alert is selected, the isolation icon will display in the patient name column

Consult Service & Consult Timer

Drop-down list of options for specialty physician consultations

When selected, the Consult Timer will start and the STS Column will update to C2C

When the consultation service arrives to the clinical unit, change the Consult Service to a blank field and update the STS Column to ADM. This will stop the Consult Timer

New Result New Result flag will autopopulate as results become available from Laboratory Services, Medical Imaging, and Non-Invasive Cardiology

Red – abnormal results Green – normal results Yellow - text document

Double click on the flag to view the results. Select Don’t Clear Flag or red X (top right corner) to close the window

BC4 Assigned &

When arrangements have been made by the physician to transfer the


BC4 Timer

patient, the STS Column will need to be updated to Pending Transfer

This update to the patient’s status will start the BC4 Timer

When a bed assignment has been entered in Patient Flow, the bed assignment will display in the BC4 Assigned Column with the bed number and the readiness of the bed:

Brown – dirty Grey – occupied Yellow – process in cleaning Flashing green – clean

Comments Free text

Examples for using this column are: Specifying a second consult service Transportation arrangements Special tests (e.g. lung tap)

Entering in Data

There are several different ways that patient data can be entered on the status board:

Drop-Down Lists

Drop-down lists allow for a single selection to be chosen. To select the blank field or option for

the cell in a column, open the the drop-down list and select the blank field


Free Text Cells

Select the patient. Single click in the cell to enter data

Checkbox Cell

Select the patient. Click in the box to add a checkmark. In the example below, one of the

patients is being cardiac monitored as indicated by the checkmark

Icons in the Patient Name Column

indicates that the patient is on some type of isolation precaution

indicates that the patient has requested that they be treated as a “Confidential Person” –

which is entered in Sunrise Enterprise Registration. The patient name will display as a white cell,

but you can select the patient and their information will still be displayed in the header. All

other information will display as usual

indicates a patient 70 years of age or more. This is a ‘heads up’ to all health care workers to

provide urgent intervention and services to patients that may assist in preventing hospital

admissions in the emergency department. Furthermore, on clinical units this icon identifies

patients that may need more services on discharge


Locking Columns

You can lock selected columns so they remain visible when you scroll horizontally. To lock columns, right-click the last column to keep locked and choose Lock Column

The shaded columns indicate the locked columns

Unlocking Columns

To unlock columns, right-click a specific column and choose Unlock Columns

Show History

To show the history on any cell, click on the cell > right-click and select Show History

This will show a record of all changes made to the cell and by whom


Removing a Patient from the Status Board

**Prior to removing a patient from the status board, please check with your educator as to who

is performing this work**

Select the patient you wish to remove and right-click on the mouse. A list of options will appear

Select Remove Patient. Patient will be removed to the Inactive Patients list

Returning a Patient to the All Beds View

If a patient has been removed from the All Beds View in error, go to View above the status

board

Open the drop-down list and select Inactive Patients

Select the patient you want to return to the All Beds View. Right-click and select Return Patient


A Return Patient menu opens asking you what location that you want to return the patient to.

Click the down arrow for a list of locations. Select the location. Click OK

Discharging Patient from Status Board (Emergency Department Only)

This step is completed when a patient has left the emergency department. However, only

applies to ED visits and not ED inpatient visits

1. Patient is removed from the Status Board by the Emergency Department RN and is now on the Inactive Patients list

2. Find patient on Inactive Patients list, right-click on patient and select Discharge Patient


3. From the Visit Discharge window, click on the drop-down arrow for Actual Date and click on the date the patient was discharged

4. Click in the Actual Time textbox and type in the time of discharge 5. Click on the drop-down arrow for Disposition and select the disposition 6. Click on the drop-down arrow for Discharge Location and select the location the patient

was discharged to 7. If additional notes need to be added about the discharge, click in the Notes text box and

type in the additional information 8. Click on the Discharge command button

*Please note that items 3-6 are mandatory fields*

ED Visits – ED staff to complete discharge

ED Inpatient visits – ACAS PPC’s to complete discharge

For patients that expire in the ED:

Time of Death to be used as discharge time

ED visit expirations – follow ED visit discharge process

ED Inpatient visit expirations – ACAS PPC’s to complete discharge **Patients will remain on the Inactive Patients list for up to four (4) hours once the visit is discharged, or indefinitely if the discharge process is not completed**

How to Revert an Accidentally Discharged ED Visit

Make sure you have the patient in context. If not, you need to perform a patient search to find

the patient


Select the correct visit from the Show Visits menu. The correct visit will have a Visit

Status of DSC

Double-check that you have the right patient in context. The patient will have a DSC date in the

patient header

1. Select Patient Info Tab

2. Under the Data Entry section click on Discharge

3. A Visit Discharge menu will open. Make sure information is correct and select Cancel

Discharge

4. The Location Menu will open. Under the New Location section, check that it is set to the

bed the patient was previously in. You can click on to assign a different bed if

needed. Click OK. The patient header will no longer have a DSC date


Section: Flowsheet Documenting A to Z

Airway Assessment of Drooling

1. Click on Flowsheets tab and select ED Assessment and Care

2. Expand EENT

3. Throat Assessment-Drooling

4. Add comments for specific airway concerns

Arterial Blood Pressure and Arterial Line

1. Click on Flowsheets tab and select ED Vital Signs

2. Right-click on row header, click on Add Parameter


3. Select Blood Pressure then Select Arterial Blood Pressure, click Add then OK

4. Document arterial blood pressures here




7. Select Access Device, then select Arterial Line, click Add then OK


8. Document ‘Inserted by Dr.(name)’ in the free text box, as well as any patient/family

teaching done

9. Document Waveform and Site Care in these areas

Cast Application and Ongoing Cast Assessment


2. Expand Musculoskeletal


3. If procedure done by physician, document ‘Done by Dr.(name)’ in the free text box, and

document patient/family teaching done

Central Line Insertion and Ongoing Care Documentation




3. Select Access Devices, then Central Line, click Add and OK

4. If procedure done by physician, document ‘Inserted by Dr.(name)’ in the free text box.

Also document any problems encountered in the insertion as well as patient/family

teaching done in the free text box


5. Row label may be modified if more than one Central Line present

6. Remember to document infusions on the Intake and Output flowsheet

Chest Pain Assessment

1. Click on Flowsheets tab and select ED Assessment and Care, expand Cardiovascular

2. Remember to Add Parameter for cardiac monitoring/ECG rhythm, as well as any heart

sounds heard on assessment


3. Other cardiovascular assessment (e.g. edema) is done under Assessment and

Care/Vascular

4. Completion of 12 lead ECG and collection of lab work need to be documented on the

Progress Note (Vital Signs/Nursing Information/Progress Note)


Chest Tube Insertion and Ongoing Assessment




3. Select Respiratory, then select Chest Tube, click Add and OK


Also place your comments as to how the patient tolerated the procedure here

5. Row label may be modified to reflect location if more than one chest tube present


6. Remember to add the Chest Tube to Intake and Output and record drainage, and label

the row with chest tube location as noted in Chest Tube observation

Colostomy Assessment




3. Select Gastrointestinal, then select Colostomy, click Add and OK

4. Document ongoing Colostomy Care here

5. Go to Intake and Output flowsheet to document drainage: Right-click and select Add

Parameter - select GI then Colostomy


Continuous Bladder Irrigation (CBI)



3. Select Genitourinary, then select Bladder Irrigation, click Add and OK



Also include any information regarding problems encountered, and patient teaching

Do not forget to add an Indwelling Catheter of the appropriate size and type


5. Enter Irrigation on Intake and Output: Go to Intake and Output and Add Parameter

under Intake - Net

6. Any problems with Bladder Irrigation, or if catheter occludes with clots and needs

manual irrigation, document here


Distal Extremities Assessment and Capillary Refill

Click on Flowsheets tab and select ED Assessment and Care, expand Vascular assessment, add

time column to chart

Endotracheal Tube




3. Select Respiratory and expand to see subcategory

4. Select Artificial Airway

5. In time column, under Type, click and select endotracheal tube and click OK

6. Document ‘Inserted by Dr.(name)’ in the free text box. Also document what was done

with ET tube (e.g. attached to ventilator, ventilator settings, bag valve mask, etc.)

7. Re-label the specific airway type to ET tube: Right-click on Artificial Airway row/Modify

Row Label: Label artificial airway as ET tube


Enema




3. Select Gastrointestinal, then select Enema, click Add and OK

4. Document Enema as outlined:

5. Document patient response to enema. If patient having pain post-enema, will need to

go to Pain assessment to document pain assessment there


HDC (Hypodermoclysis – Subcutaneous Infusion) Assessment



3. Select Access Device, then Subcutaneous Infusion, click Add and OK



5. Remember to document infusions on the Intake and Output

Hemovac Assessment




3. Select Skin, then Drainage Tube, click Add and OK

4. In time column, click “Type” and select Hemovac


5. Remember to add Hemovac to Intake and Output

Ileostomy Assessment




3. Select Gastrointestinal, then select Ileostomy, click Add and OK

4. Remember to add to Intake and Output

Incentive Spirometer





4. Select Incentive Spirometer, click Add and OK

Incision Assessment




3. Select Skin and expand to see subcategory

4. Select Incision #1, click Add and OK

Indwelling Catheter Insertion and Care

1. Click on Flowsheets tab and select ED Assessment and Care, then select Genitourinary.

Document your assessment and care


2. If procedure done by physician, document ‘Inserted by Dr.(name)’ in the free text box,

as well as any issues encountered, and patient teaching

3. Ongoing assessment and care is documented in intervention area

Intermittent Catheter Documentation

1. Click on Flowsheets tab and select Genitourinary

2. Under GU Assessment, select Void Route, then choose appropriate route


3. Do not forget to document if you sent a specimen or if you need to record an Intake and

Output volume

Infusion – Documenting a Heparin Infusion

1. Click on Flowsheets tab and select Intake and Output

2. Right-click on row header, click on Add Parameter/Drips/Heparin


3. Document bag info and rates in time box as per other IV infusions

Ensure you document repeat PTT in row label, and document dose, PTT result, and stop/re-

start times


Right-click on observation area and click “Modify Row Label”, enter required information into

“Comments:” box

*ENSURE you document the actual dose of heparin on MAR!*

Intake and Output Flowsheet

Jackson-Pratt (JP) Drain Assessment



3. Select Skin, then Drainage Tube, click Add and OK


4. In time column, click Type and select Jackson-Pratt

5. Make sure to document the Jackson-Pratt volumes on the Intake and Output sheet


JVD (Jugular Venous Distention) Assessment



3. Select Cardiovascular, then Jugular Venous Distention, click Add and OK


Memory Assessment



3. Select Neuro, then Neuro Deficit, click Add and OK


Mobility and Ambulation Assessment

1. Click on Flowsheets tab and select Vital Signs

2. Select Continuing Care, then Activity. This is where you will document the on-going

mobility assessment

3. In ED Nursing Admission, you can also complete the Fall Risk/TLR Screening if not

completed on the initial documentation

Mucous Fistula Assessment




3. Select Gastrointestinal, then Mucous Fistula, click Add and OK

4. Add any additional comments in the Interventions box


Nasal Trumpet






5. In time column, under Type, click and select Nasal Trumpet and click OK



Document how patient tolerated procedure, problems encountered, patient teaching,

etc.

Nasogastric/Orogastric Tubes


2. Right-click on row header, click on Add Paramete

3. Select Gastrointestinal, then select Nasogastric/Orogastric tube, click Add and OK



Also, make sure you chart how the insertion was tolerated, problems encountered, and

patient/family teaching

5. Add time column for ongoing assessment of Nasogastric or Orogastric tube

Nasogastric/Orogastric Tube Fluid Replacement Documentation

1. Click on Flowsheets tab and select Intake and Output

2. Right-click on row header, click on Add Parameter/Crystalloid/(ordered fluid type)


3. Label row with reason for fluid line

4. Leave bag active until done with replacements

Nasopharyngeal Tube






5. In time column, under Type, click and select nasopharyngeal airway and click OK


as well as how procedure was tolerated, any problems encountered, and patient/family

teaching


Nasotracheal Tube






5. In time column, under Type, click and select nasotracheal tube and click OK


Nebulizer Administration Documentation

1. ED Vital Signs flowsheet, Respiratory


2. Go to Oxygen Therapy section – enter in Flow and in comments section under Delivery

Method, type ‘Nebulizer’ if patient uses nebulizer pipe, otherwise use Delivery Method

type mask, aerosol

3. Be sure to chart the medication given in the MAR

Nephrostomy Tube Assessment



3. Select Genitourinary then select Nephrostomy, click Add and OK


4. Remember to label the row with location of tube (right or left)

5. Add second Nephrostomy tube if needed, and label row

6. Remember to add Nephrostomy tube to Intake and Output, and label the rows in the

Intake and Output record

Oropharyngeal Tube






5. In time column, under Type, click and select oropharyngeal airway and click OK


as well as how patient is tolerating the airway, any issues, and patient/family teaching


Penrose Drain Assessment



3. Select Skin, then Drainage Tube #1, click Add and OK

4. In time column, click Type and select penrose


5. Document the Location and any other information about the drain site

6. Remember to add the drain to the Intake and Output and label the drains in the Intake

and Output

Peripheral Pulses Assessment




3. Select Vascular, then select appropriate pulses (e.g. radial pulses), click Add and OK. For

central pulses, select appropriate location (i.e. carotid, brachial), and document the

central pulses (as we do with pediatric patients)

PICC Line Insertion and Assessment




3. Select Access Device, then PICC #1, click Add and OK

4. Document ‘Inserted by Dr.(name)’ or ‘Inserted in radiology at (time). In the free text

box, how the patient tolerated procedure, patient teaching, and on-going assessment

and care for the line/site will also be documented in this area


5. Go to Intake and Output and enter PICC. Label the row as done for IVs, chest tubes, etc.

Rash




3. Select Skin, then Rash, click Add and OK

4. Should be enough detail to document here. Note the drop-down menu choices for

additional documentation. There is a free text box for additional information, if needed


Scrotum/Penis Injury

1. Click on Flowsheets tab, select ED Assessment and Care and then select Pain Assessment. Document Pain Assessment. Note the drop-down menu choices for additional documentation


3. Select Skin, then Bruising, click Add and OK


4. Should be enough detail to document here. Note the drop-down menu choices for

additional documentation. There is a free text box for additional information, if needed

Stroke Screening Assessment (FAST)

1. At Triage:

a. On left navigation panel, expand Screening/Treatment/Protocols and select STROKE

SCREEN

b. When entering information on last seen normal, month must be typed out (i.e. Aug),

or use calendar accessed by clicking “C” button on date/time box


2. Stroke Screen is also done under Assessment and Care/Neurology/Stroke Assessment

(FAST) or in EDNA under Screenings/Stroke. This would be done with patients that

developed stroke signs and symptoms after Triage completed

Subcutaneous Emphysema





4. Select Subcutaneous Emphysema, click Add and OK

5. Document areas of Subcutaneous Emphysema, comments section for additional

documentation

Suprapubic Catheter




3. Select Genitourinary, then select Suprapubic, click Add and OK

4. Document the size, physician who inserted it, patient response, patient/family teaching.

There is a comments section to document additional information


5. Remember to document the Suprapubic catheter in the Intake and Output. Label the

row with Suprapubic Catheter

Swallowing Assessment




3. Select Neuro, then Swallow Screen, click Add and OK

4. If procedure done by SLP, document ‘done by SLP’ in the free text box and add ‘see SLP

swallowing results’

Tracheostomy





4. Select Tracheostomy, click Add and OK

5. Document ‘Inserted by Dr.(name)’ in the free text box – comments (if done in ER)


6. Document information in appropriate sections. Comments should also include

information on patient teaching to family/patient

Traction, Splint and Cast Assessment




3. Select Musculoskeletal, then Traction, click Add and OK

4. If procedure done by physician, document ‘Done by Dr.(name)’ in the free text box


***Remember that Conscious Sedation will be documented on paper – on our current

Conscious Sedation Record. In progress notes (on electronic record), please make a note to

refer to further documentation on paper Conscious Sedation Record

Urine Specimen Collection


2. Select Genitourinary, then Void Route, choose appropriate route


3. Select Urine Specimen, Status. Choose appropriate options

4. Select Testing Type. Choose appropriate options

Visual Acuity Assessment

1. Click on Flowsheets tab and select ED Assessment and Care. Expand EENT

2. Use the Snellen chart to obtain the information to document in the Visual Acuity fields


Wound Treatment/Ongoing Wound Assessment



3. Select Skin, then Wound #1, etc. … Can add up to 3 wounds, click Add and OK


4. In time column, add column and document about the wound


5. Ongoing wound care to be documented in additional time columns

Section: PEDS Documentation

Pediatric In and Out Catheter Using a Feeding Tube

1. Assessment and Care-Genitourinary

2. Urine Void Route

3. Click Catheterization, Intermittent

4. In Comments Document: Size of Feeding Tube, used for Intake and Output cath,

Description of Urine (small amount of dark yellow urine) and patient’s tolerance. Include

any patient teaching here


Broselow Tape

1. Vitals Signs Document-Body Measurements

2. Document Estimated Weight according to Broselow, enter weight and then select

weight calculation tape, pediatric

3. Specify Broselow Colour by right-clicking in the body measurement section, click modify

row label and then enter colour of Broselow in the comments section

Central and Peripheral Capillary Refill

1. Assessment and Care-Vascular Section-Distal Extremity Check

2. Cap Refill - if normal, select 2 seconds or less

3. Cap Refill - if delayed, do not select either option and specify how many seconds in the

comment box

4. Location - if wanting to specify central, enter in comments ‘central location’

5. Location - if wanting to specify distal, select the appropriate location in the prewritten

boxes


Child – Breastfed, Bottle or Pedialyte Given

1. Intake and Output Flowsheet-Oral Intake

2. Add Parameter-Oral-Choose appropriate oral intake, click Add then OK

3. Breastfeeding is calculated in minutes per side, all other oral fluids is calculated in mL


Fontanelle

On Assessment and Care – Skin, Fontanelle. Use free text box to add additional information as

needed

SCM Clinical Documentation Manual.pdf - Saskatoon Health ...

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