Sunrise QRG - Inpatient Clinical Clerking : MTW IT Service Desk

This guide is for all medical staff in inpatient wards. It provides an overview of completing the inpatient clinical clerking document for adult patients on Sunrise.

Step	Tips/Notes
	Note Please refer to ‘Creating Documents – Key Points’ quick reference guide and/or video for more information on managing documents. Documents created can be viewed by all staff with the appropriate access right on Sunrise.
1	Patient Admitted in Emergency Department (ED) If giving a specialty opinion with a view to admit a patient currently in ED, from the ‘Tracking Boards’ tab, choose the ED location from the ‘Department’ list, then select the appropriate view and highlight the correct patient so they are displayed in the patient banner. Patient Admitted in Adult Ward If the patient is admitted directly to an adult inpatient ward, from the ‘Tracking Boards’ tab, choose the correct ward from the ‘Department’ list and select the correct patient so they are displayed in the patient banner.
	Note Some frequently used inpatient documents are accessible from the Quick Launch Docs shortcut in the tracking boards. Other documents not listed can be created by selecting the ‘Enter Document’ icon on the toolbar

Admitted in ED – Adults only

If the patient is currently admitted in ED and the decision to admit (DTA) has been made and recorded, the ‘Inpatient Clinical Clerking Document’ can be started whilst the patient is physically in ED then completed once admitted and moved to the ward.

Select the ‘Quick Launch Doc(s)’ arrow and select the document, as illustrated below

OR right mouse click on the patient, choose ‘Quick Launch Documents’ then and select the document, as illustrated below

Admitted in Ward

If the patient is currently admitted on the ward, select ‘Quick Launch Docs’ at the bottom of the screen, then choose ‘IP Clinical Clerking Document’ from the list provided.

Alternatively, right mouse click on the patient, hover on ‘Quick Launch Documents’ and select ‘IP Clinical Clerking Document’

Right mouse click action performed within an adult location/ward

Note

The flow of documentation being created for inpatients must be completed in a particular order for information to be copied forward or transferred automatically into other relevant inpatient documents.

Example - flow of documentation following an admission (adult patient)

Doctor creates the ‘IP Clinical Clerking Document’.
Nurse creates ‘IP Nursing Admission’ document.
Doctor creates ‘IP Doctor Ward Round and Progress Note’ document.

Complete IP Clinical Clerking Document

The ‘IP Clinical Clerking Document’ consists of ‘tabs’ as illustrated below.

Note – VTE has now been removed from the document as this will remain on paper

The currently selected tab is highlighted in white with an orange border at the top. Hovering your mouse on each icon next to the tab name at the top provides additional information regarding why the icon appears.

– indicates some fields within the form have been automatically populated using information added in other previously completed documents.

– indicates mandatory and significant field/s needs to be completed. Icons disappear once all applicable fields on the tab have been populated. All mandatory fields must be completed before you can save.

Note – You are required to scroll further down with the scrollbar on the far right of the page to see other relevant fields to be completed.

Complete fields on each tab as required before saving the document.

5	Actions/Information bar Action bars appear based on certain selections made within the document. They prompt medical staff on actions to consider or take next. Use your clinical judgement to make the appropriate decision.
6	Quick Actions buttons There are action buttons within some tabs. For example: Referrals can be requested to other teams or specialities from within the document at the click of a button as illustrated below. See ‘QRG – Place a request for referral’ for more information. Latest information completed elsewhere in the patient’s record, i.e. observations, can be inserted automatically using a button. It is recommended that the button is selected even if information is currently displayed, to ensure the most up-to-date data is displayed.
7	Conditional Triggers These occur when a selection is made on a radio button option with ‘…’ at the end. A question answered on the document could trigger additional questions to appear, either to the side or underneath. Example: ‘Never smoked’ does not trigger any additional questions. But ‘Former smoker…’ triggers further questions, as shown.
8	Assessment Scores Some fields automatically calculate scores based on the entries made
9	Body Map Images Within the ‘Review of Systems’ tab, different body map images can be enabled by selecting ‘Yes…’ to the question “Do you require an image?” Images can be annotated using the toolbar directly above the image.
10	Saving Document Once all tabs are fully completed, select ‘Save’ button. If the document is partly completed and not finished, tick at the bottom of the screen before selecting the ‘Save’ button. This will indicate within the documents tab that the document is in progress.
11	SCM Notice These appear as pop-ups, alerting staff about information recorded or to act on a calculated score. A message will also appear when saving a document where significant or mandatory fields haven’t been completed. Some examples are illustrated below. Staff are required to read the prompt and acknowledge or action appropriately.