This guide is for Nurses and HCAs working in the Outpatient Department who will be using Clinical Documentation on Sunrise for either Neurology or Gastroenterology patients.

 

Step

Tips/Notes

 

Note – You are able to add your most frequently used documents to access all in one place, for easy use. For more details, please refer to the Quick Reference Guide on ‘Set Favourite Documents and Default Display’.

 

1

Select the patient you require from the patient list and check the details in the patient banner. 

 

Alternatively, search for the patient, ensuring the current appointment is selected as the ‘visit’.

 

2

Click on the ‘Enter Document’ icon on the main toolbar. This is how to start a new document.

 

3

With the Enter Document screen displayed, from the ‘Start of Browse’ list showing all the document categories, select ‘Outpatient’ to display the Outpatient documents available on the right hand side

 

 

4

Or alternatively you can use the search box by typing in ‘OP’

 

5

From the OP document list, double-click on the required document to open it.

 

Alternatively select the document and click the ‘Open’ button

 

Note – a new document will open for each appointment.

6

This is an example of the OP Gastroenterology Multi Professional Record (MPR) Document, showing all the available tabs

 

 

7

This is an example of the OP Neurology Multi Professional Record (MPR) Document, showing all the available tabs

 

 

8

When the document opens, it will automatically open onto the ‘Nurse Triage’ tab

Complete the necessary fields in the ‘Nurse Triage’ tab.

 

9

Note – the Nurse Triage tab is the same in both Gastroenterology and Neurology MPR documents

 

10

If you are completing the Neurology MPR Nurse Triage tab, once completed, you may click the ‘MS Timed Walk Test’ tab and complete the fields if required.

 

This is an example of the ‘MS Timed Walk Test’ tab

 

11

Once you have finished entering the details required, as more information will be added by the Consultant, ensure the ‘Incomplete’ check box is ticked in the bottom left corner.

 

 

Then click the ‘Save’ button at the bottom of the document

 

12

If you need to return to the MPR to continue entering information, with the patient in context, repeat steps 2-5. 

 

Alternatively, with the patient in context, click on the ‘Documents’ tab

 

 

13

With the documents screen displayed, select the OP document (OP Gastroenterology MPR or OP Neurology MPR) from the appointment/visit you require (check the date)

 

 

14

Either right click and select ‘Modify Document’

 

Or double-click on the document to open and click the ‘Modify’ tab

 

Or click on the ‘Modify’ icon from the tab toolbar

 


 

 

15

Continue data entry

 

16

Once completed, ensure the check box for ‘Incomplete’ at the bottom of the document is ticked and click the ‘Save’ button

 

 

 

Title: Outpatient Documentation – Nurses & HCAs

Author: Sunrise Training Team - EW 

Date: 28/03/2021

Version:  v1.0