MTW IT Service Desk

Step

Tips/Notes

Important Note:  Therapy teams will need to use the ‘Therapies Data Collection’ flowsheet to record their contact activity as soon as Sunrise goes live.   However, the therapy ‘documents’ can only be used when the patient’s ward has switched to doing their inpatient documents on Sunrise

1

Select the patient you require from your chosen ‘Patient List’ and check the details in the patient banner.

Alternatively, select the patient from the relevant ward ‘Tracking Board’

2

Click on the ‘Enter Document’ icon in the main toolbar

3

The ‘Document Entry Worksheet’ pop-up window will open.   Ensure the date and time are correct and select ‘Start of Browse’ from the dropdown menu to display the folder choices.

4

To open the ‘Inpatient Daily Therapy Note’, select either ‘Inpatient – Adult’ or ‘Inpatient – Paediatrics’ from the left-hand column.   To open the relevant document left click on the ‘IP Daily Therapy Note’ or ‘Paediatric IP Daily Therapy Note’ from the right-hand column and press the ‘Open’ button below.  Alternatively, double click on the document to open. 

 Tip:     The Daily Therapy Note can also be located by using the search box and typing in either ‘IP’ for adults or ‘Paed’ for Paediatrics

5

Note:  For easy use, you are able to add your most frequently used documents to access in one place.  For more details, please see the Quick Reference Guide ‘Set Favourite Documents and Default Display’.

6

The Daily Therapy Note will appear and the process for completing this is the same for Adults and Paediatrics.  

Select the correct ‘Therapy Service’, for example ‘Physio’. Note:     Depending on which service is ticked additional sections may be displayed on the Therapy Note for completion. 

Always click the ‘Refresh’ button to see the most recent set of observations (even if observations are already displayed).  Use the scroll bar on the right-hand side to move up and down the document

Note:   The top half of the document is auto-populated from entries made in the Doctors Ward and Progress Note, including ‘Medically Fit for Discharge’, the ‘Estimated Date of Discharge’ and ‘Diagnosis/Problem List’

7

Scroll down the Daily Therapy Note to locate the ‘Therapy Notes’ section.   This is where Therapists will enter their data

8

Click ‘Yes’ to activate the body map

9

Use the toolbar images to annotate the Body Map as necessary.  For example, you can add a circle with an X, add an arrow or insert text to point out important information or highlight an area on the image

Tip - once you have clicked on a symbol from the body map toolbar and inserted the information required, make sure you click the symbol again to deactivate it.  If you wish to delete an annotation, right click on the annotation and then select ‘Delete’ from the menu options.  Alternatively, select the annotation and press the delete key on the keyboard

10

Complete all relevant information in the appropriate SOAP freetext fields, including recording if the patient has capacity to consent and consent given.   

Note:  For further details on completing documents see Quick Reference Guide and video ‘Creating Documents – Key Points’.   Also refer to the QRG and video for ‘Mental Capacity Assessment’ 

11

Once complete, click on the ‘Save’ button on the bottom right of the screen

12

Important Note:  All entries made on documents and flowsheets will automatically show the name of the logged in user. It is essential NOT to share login details for Information Governance reasons

13

Now click on the ‘Flowsheets’ tab to record your contact activity 

14

In the ‘Options Panel’, under ‘Flowsheets Selection’, select the flowsheet ‘FS Therapies Data Collection’

Note:  For further information on Flowsheets, see Quick Reference Guide ‘Flowsheets – Key Points’

15

The flowsheet will now be displayed in the centre of the screen.    Expand the ‘First Contact’ parameter by clicking on the ‘+’ icon 

Note: The flowsheet parameters are subject to change, however, the process for entering data will remain the same

16

To enter information into the Flowsheet, click on the ‘Add Time Column Options’ icon from the tab toolbar

17

Select ‘Add Single Time Column’ from the menu options

18

The single time column pop-up screen will now appear, the current date and time are automatically entered, use the arrows at the sides if any changes are required, then click ‘OK’

19

The new date/time column will be added to the Flowsheet.  

20

To complete the ‘First Contact’ section, click into the time/date column.     Individual pop-up windows will appear for each field.  Enter the appropriate data and then click ‘OK’ to move on to the next field.  

21

Important Note:  The following information will aid completion of the ‘First Contact’ section of the flowsheet:   

22

Once you have completed your entry, click on the ‘Save’ button, in the top right hand side of the Flowsheet

23

Note: When more than one Therapy team is involved in the patient’s care, they will have their own documents but will share the same Therapies Data Collection Flowsheet.      For further details see Quick Reference Guide ‘Inpatient Therapies – Multi-Team Involvement’