This guide is for Neurology and Gastroenterology Consultants and Registrars who will be using Clinical Documentation to update the patient’s record on Sunrise during their Outpatient clinics

 

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 ‘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 you can alternatively 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

The outpatient Nurse may have made entries in the Triage tab. In the Neurology Multi Professional Record (MPR) document, for MS patients, they may have completed the MS Timed Walk Test tab. Select the tab(s) to view the entries

 

9

Within the OP Gastroenterology Multi Professional Record (MPR), there is a single tab for the Consultants & Registrars – 

  • Gastro MPR

 

Within the OP Neurology Multi Professional Record (MPR), there are 3 tabs for the Consultants & Registrars – 

  • Neuro MPR
  • MS Consultant MPR
  • Botox GJS

 

10

Click onto the Consultant/Registrar tab that you require. Below is an example of the ‘Neuro MPR’

 

 


 

 

11

Note: In the ‘MS Consultant MPR’ tab, the Medication/Drug Monitoring section must be completed correctly as this information is used in the pharmacy audit.

 

12

Note: There are additional tabs on both MPRs that are used by the Specialist Nurses. Gastro Consultants and Registrars may wish to use the Calculations tab.

 

13

Once you have finished entering the details required, click the ‘Save’ button at the bottom of the document

 

If more information for this appointment is to be added later, ensure the ‘Incomplete’ check box is ticked in the bottom left corner before saving and the status of the document will show as ‘Incomplete’ on the Documents tab

 

14

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

 

15

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

 

 


 

 

16

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 on the tab toolbar

 

17

Continue data entry

 

 

18

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

 

The status of the document will show as ‘Complete’ on the Documents tab

 

19

A new MPR document is completed for each outpatient appointment, whether with the Consultant or Nurse Specialist. 

 

Previous MPRs can be viewed in the documents tab.  For more details, please refer to the Quick Reference Guide ‘Creating Documents – Key Points’.

 


 

 

Title: Outpatient Documentation – Consultants & Registrars

Author: Sunrise Training Team - EW 

Date: 28/03/2021

Version: v1.0