ProvClinicals

1. ProvClinicals Horizon Expert Documentation Module 3: Charting

2. This is the third of five modules in this course on Horizon Expert Documentation. This module will focus on the charting aspects of HED.  By the end of this module you will be able to: Identify different aspects of the charting screen.  Chart patient health information pertaining to the assessment, planning, intervention, and evaluation of a specific patient. Modify single entries of previously charted information. Delete a single entry. Copy, modify, move, and clear an entire charted episode of previously charted information. Mark entries as significant. Add a free text comment to your chart. 2

3. Once you have chosen a patient's chart in Care Organizer, click on the NurseChrt button.  This will take you into the flowsheets. We are going to go through the different parts of the flowsheet, show what they do, and orient you to what they mean. 3

4. Notice along the top of the screen there is a blue title bar.  This is the title of the page you are on:  Logged in User: 213 E NURSE TRAIN Below the title bar is the menu bar.  This is the same menu bar that we looked at in the Care Organizer lesson. 4

5. The patient's name is under the menu bar.  This is the patient chosen in the Care Organizer. The arrow next to the patient's name allows you to choose a different patient on which to chart.  This makes it easier to move from one patient's chart to another without returning to the Care Organizer. 5

6. If you forget to select a patient in the Care Organizer, this box automatically opens up to the floor's census. Let's see the different ways to choose a chart from here.  Click here to see a demonstration. 6

7. Next to the white box containing the patient’s name, the Allergy button displays.  To the right of the Allergy button you will see two flags: A yellow exclamation point (!) for Care Alerts, and A Privacy button The purpose of the Care Alert is to alert you that something is missing from the patient's charting.  The purpose of the Privacy button is to alert you that this is a privacy, or opt-out, patient and you should follow the policies for these types of patients accordingly.  We will discuss viewing and clearing Care Alerts later in this module. 7

8. Next are the Refresh button and the VS_DAS button. Use the Refresh button whenever you need to refresh the data on your screen.  This may be after another clinician has entered data, or after administering a medication or IV fluid. The VS_DAS button is used only in the ICU/CCU units.  This button is the link between the monitors and ProvClinicals.  We will talk more about this button later in this module. 8

9. The lighter-colored banner that runs below these items contains demographic information such as:  age gender attending physician facility-department date of birth account number diagnosis service room-bed admit date medical record number (MRN). 9

10. Below the banner you will see all of the CRVs, or flowsheets, displayed.  CRV stands for Chartable Reviews.  There are two ways to open a flowsheet. First click on the tab, or CRV.  Each tab has a title with a short description of what can be documented on that tab. 10

11. Notice that various flowsheets are used for assessing, planning, documenting, and evaluating patients' health information and treatment. You may also access the flowsheets by using the Chart option on the Menu bar.  Click here for a demonstration on the two ways to open a flowsheet. 11

12. ProvClinicals flowsheets are designed to imitate the feel of flowsheets found in older style paper charting. All of the flowsheets are used in the nursing process of assess, plan, intervene, and evaluate.  An example of a flowsheet that is used during a patient assessment is the VS_I/O_POC flowsheet. Many of these flowsheets can actually be used to accomplish more than one step in the nursing process.  An example of this is the Med Admin flowsheet where you can administer medications, and you can also chart the patient's response to the medication. The flowsheets have a cross-walk functionality. Charted data on one flowsheet will automatically move to all the other flowsheets with that same label.  This helps to eliminate double charting. 12

13. To begin charting, you need to click on the Chart button on the flowsheet.  This will change the chart from the review mode to the charting mode. The process when charting is simple to follow and master.  A more difficult aspect of charting is WHERE to chart.  If you are not sure where to chart certain information, talk to your manager or look at procedures for your specific unit or facility. Let's learn how to chart!   Click here to see a demonstration. 13

14. During the charting process, you may need to indicate that the individual result just charted is significant. To accomplish this, click on the exclamation mark next to the charted data. Click here to see how the exclamation mark works. There may also be moments while you are charting that you want to add more details to your charting.  You may use the free-text annotation notes to accomplish this. Use these notes with caution.  This is NOT the preferred method for charting since the chart has dropdown choices for most of your charting needs. Let's see how a note would be entered, and what it would look like in the chart. Click here for a demonstration. 14

15. Now that you've seen charting, let's practice!  This will be a guided practice with directions for you to follow.  Here is the scenario: Your patient has consumed one glass of apple juice (120cc).  You have emptied 400cc of urine from her catheter bag.  VS: BP=118/88, T=99F (oral), P=86, R=20 She is 5'11" and weighs 180 pounds.  Her blood glucose was 72.  She has an isolation status of contact precautions.  Her pain rating is 3/10.  Her SpO2 is 98% when resting quietly. Click here to practice charting the above data. 15

16. This is how the final charting should look on the flowsheets.  Notice how the date and time that the data was charted is located at the top of each column.  Also, the flowsheet allows you to view the last 6 charted episodes. Remember that the charting you see in the review mode is part of the permanent chart. Now that you have seen charting, let's look at the different ways in which you may modify any charted data.  You may chart data either in the Review Charting Session, or on the permanent chart in review mode. 16

17. Let's look at the Review Charting Session.  This screen opens when you click on the Save button.  In this screen, you can review and make changes to the data you have charted. Since you have not clicked on the Confirm button in the Review Charting Session screen, you can modify your charting BEFORE it becomes part of the permanent chart. This allows you to correct any errors before the final save. Continue on to explore the different options that are available to modify your charting in the Review Charting Session. 17

18. When changes to patient data are made in the Review Charting Session, the data are not yet part of the permanent medical record.  This is the preferred place for you to review your charting and make any changes before confirming. Let's see what it looks like to modify data after you have saved it, but not yet confirmed it (the Review Charting Session).  Click here for a demonstration. 18

19. Oops!  When reviewing your charting, you discover that you have accidently charted data on the wrong patient.  You can discard all of the data before it becomes part of the permanent record. You do not have the ability to cut and paste the data into another patient's chart. Let's see how to discard charted information from the Review Charting Session.    Click here for a demonstration. 19

20. Here is another situation that might require that you modify your charting. While reviewing the charted data, you notice that you forgot to chart all of the information you had gathered.   Clicking on the Back button will take you back into the chart to enter the missing data.   Click here for a demonstration. 20

21. Another handy tool in ProvClinicals is the Chart New button. This button will allow you to quickly chart multiple episodes while at the computer without starting from the beginning. For instance, you have gathered vitals on your patient, and while entering them in the computer, your patient falls.  Since patient care always comes first, you need to take care of the patient first.  You would, of course, take the patient's vitals again, and want to chart both pre-fall and post-fall vitals in the correct times. Let's see how you would chart both of these incidents.  Click here for the demonstration. 21

22. You may have noticed in the lower left-hand corner the Cosign button. The purpose of the Cosign button is to allow a another clinician to cosign for charted data.  When you cosign on this screen, you are cosigning for everything on the Review Charting Session. This button is usually used when you cosign for nursing students, but may be used whenever you feel necessary. Please follow the different facilities' policies concerning cosigning. Click here for a demonstration. 22

23. After you have clicked on the Confirm button in the Review Charting Session, the data you charted is now part of the permanent medical record for this patient. Occasionally you may need to change or modify you charting after it has become part of the permanent chart.  ProvClinicals supports modification of charted data at different times in your charting.   Let's look at the different ways that you can accomplish this. 23

24. Let us assume you have incorrectly entered the Isolation Status as “continued” instead of “discontinued.”  If you have already clicked on Confirm in the Review Charting Session, the finding is now part of the permanent chart, even though it is incorrect.  Let's change this. Remember that when you change data in the permanent chart it is easier to track. Click here for a demonstration. 24

25. If you enter data and want to clear it or delete it from the permanent chart, you may do so. We just modified an individual result, let's clear that modified result in this example since you entered the data on the wrong patient's chart. This is an especially helpful tool when you have administered medication to a patient, and then the patient vomits the medication. Click here for a demonstration. 25

26. We've learned how to modify individual charted results.  ProvClinicals also allows you to modify entire charted episodes.   We are going to look at how to: Copy your charting forward to a new time Modify data for an entire time Move the data from one time to a different time Clear data from a specific time   Note:  These functions are available on every flowsheet except the Med Admin and IV Admin flowsheets. 26

27. You charted all of the information you needed on your patient at the beginning of your shift. It is now the end of your shift, and the patient's condition is essentially the same.  Instead of going through the process of re-charting everything, you can copy your previously charted information forward to the current time. Let's see what this looks like when we copy forward. Click here for a demonstration. Note:  you may not copy forward other clinician's charting. 27

28. You have seen how to modify individual charted results earlier in this module.  You may also modify an entire charted time. While charting, you were interrupted, hastily charted data, and had to leave Hilde Capri's skin assessment unfinished.  Now that you have returned, you look at your charting and realize that you charted most of the assessment in error.  Let's modify the skin assessment for Hilde Capri that was charted at 09:52. Click here for a demonstration. 28

29. While working with a patient, you may not have the opportunity to chart until after some time has passed. When you do finally get to charting and you have saved your data to the current time, you may want to move that entire charted time to reflect the actual time you gathered the patient's data. ProvClinicals has a feature that allows you to move your charted time to a different time. 29

30. You can also choose to move part of your charting to a different time, and keep part of your charting at the charted time. Let's see how you would move an entire charted time, and how to leave part of the charting at the previously charted time. Click here for a demonstration. Note:  you have 24 hours to move charted data. 30

31. Let's say that you forgot to verify that you had the correct patient's chart open, and you have now charted all the information for Sassy Capri on Hilde Capri's chart. You will need to clear the charted data on Sassy's chart and re-enter the data on Hilde's chart.  ProvClinicals also allows you to clear some of the charted data, and keep some of the charted data at the current date/time.  In this scenario, we will say that the information we keep is applicable to Sassy's chart. 31

32. Let's see how you can clear an entire charted episode while keeping some data.  Remember that you may not clear other people's charting. Click here for a demonstration. 32

33. Earlier in this lesson, we located the Care Alerts flag, the Refresh button, the Privacy button, and the VS_DAS button, and briefly described how they are used. In the next part of this lesson we will: Review each of these functions Explain what they mean and why they are used View data Clear data Chart data using these buttons   33

34. A Care Alert is denoted by the yellow exclamation mark (!) adjacent to the patient name. Care Alerts are triggered when a clinician fails to complete a mandatory part of charting. After a Care Alert is triggered, you will need to view it and clear it from the chart.  Once a Care Alert triggers, it will remain with the patient's chart until a clinician clears it.     Let's look at how to view and clear the care alerts. Click here for a demonstration. 34

35. A patient may choose whether they would like privacy status or not.  If a patient has a status of Privacy, you will see the Privacy button in 2 different spots. First, in the upper right-hand corner of the Care Organizer next to the allergy button, you will see a light blue privacy button indicating that the patient has this status.  Second in the flowsheets, a privacy button will also appear at the top of the screen. Please pay close attention to the policies in your facility concerning those patients with privacy status. 35

36. One of the nice features of HED is the Refresh Button. This button allows more than one clinician to chart for the same patient around the same time.  When you click on the Refresh button, the other clinicians' charting will appear in the review mode of the chart. Let's see what that looks like! Click here for the demonstration. 36

37. The VS_DAS button located next to the Refresh button is used only in the ICU/CCU units.  This feature links the chart and the monitors in the room.  When a clinician clicks on this button, a separate screen will open.  After reviewing the monitor results, the chart will automatically download the information from the monitor into the patient's chart. Click here for a demonstration. 37

38. This concludes the module on Charting.  You can now continue with the HED course by closing this module and clicking on the next module. Thank you! 38