Sunrise QRG- Inpatient Nursing Admission : MTW IT Service Desk

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

N.B. Documents can be viewed by all staff with the appropriate access rights

Step	Tips/Notes
	Note Please refer to ‘Creating Documents – Key Points’ Quick Reference Guide and/or video for more information on completing documents.
	Note The ‘IP Nursing Admission’ document can be started as soon as the ‘IP Clinical Clerking Document’ has been started or completed by the medical staff. However, if this document is started first, then some sections will remain blank and will not automatically pre-populate from the ‘IP Clinical Clerking Document’.
1	From the ‘Tracking Boards’ tab, select the relevant ward from the ‘Department’ list and choose the correct ‘view’ from the dropdown. Then select the appropriate patient.
2	Next, at the bottom of the screen, click the arrow on the ‘Quick Launch Doc(s)’ button and choose ‘IP Nursing Admission’ from the list provided. Alternatively, right click on the patient’s row on the tracking board, choose ‘Quick Launch Documents’ and then select ‘IP Nursing Admission’ from the dropdown list.
	Note Frequently used inpatient documents are accessible from the ‘Quick Launch Doc(s)’ shortcut option. However, other documents can be created by from the ‘Enter Document’ icon on the main toolbar.
3	The ‘IP Nursing Admission’ document will open and should be completed by nursing staff for adult patients admitted to the ward. There are several tabs across the top of the document. The currently selected tab will be highlighted in white with an orange border at the top. Hover your mouse over any icons shown in the tabs to provide additional information. indicates that some fields within the form have been automatically pre-populated from previously completed documents, i.e. IP Clinical Clerking. indicates any mandatory (red) and significant (blue) fields that need to be completed. These icons will disappear once all applicable fields on the section have been populated. All mandatory fields must be completed before you can save the document as ‘complete’.
4	Tab - Relevant Clerking Information Displays a summary of information completed by the medical staff within the IP Clinical Clerking document. Use the scroll bar on the far right of the page to scroll down to view the information recorded. Some fields will generate an entry on the appropriate ward tracking board, for example ‘Red Tray’ and ‘Nutrition and Hydration’ Fluid balance will be completed on paper Stool chart will be completed within the ‘Flowsheet’ tab If the ‘Assessment for Risk of Falls’ is completed in this tab the details will copy forward into the patient’s flowsheet. It also flags on the tracking board that the assessment has been done.
5	Tab: - Activities of Daily Living This can be completed fully before navigating to other tabs
6	Tab - Infection Control Screening This information be completed within the ED Triage and ED Clinical Documentation (for patients admitted from ED) and will copy forward to this tab. However, information can also be started, added or amended within this tab. If the patient is staying in hospital for over a week a standalone document will need to be completed, ‘Inpatient Infection Prevention and Control’
7	Tab - C-Diff Risk Assessment Completed on admission within the Nursing Admission document but, if the patient is staying in hospital for over a week, a standalone document will need to be completed, ‘Inpatient Infection Prevention and Control’
8	Tab - RRA – D&V Risk Assessment Completed on admission if patient is presenting with diarrhoea and vomiting. If this occurs after admission, the Rapid Risk Assessment can be completed as part of the ‘IP Infection Prevention and Control’ document.
9	Tab - Dementia Screening Dementia screening information will be copied forward if it has been completed within the Inpatient Adult Clerking document or ED Clinical Documentation document (if admitted from ED). A purple flower badge will reflect this on the Tracking Board
10	Tab - Social Care This will display any information that has been completed within the ED Clinical Documentation or Inpatient Adult Clerking Document
11	Nursing Admission Document – Key Points Actions/Information bar: Action bars appear based on certain selection made within the document being completed. It prompts nursing staff on actions to consider or take next. Use your clinical judgement to make appropriate decisions. Conditional Triggers Triggers 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 be answered by staff. The additional questions might appear on the side or underneath the current question. Example – ‘Yes…’ selection triggers another question to the right of the screen. Assessment Scores Some fields automatically calculate scores based on radio buttons selection. Quick Action buttons There are action buttons within some tabs to aid staff when completing the nursing admission document. For example, certain investigative requests and/or referrals can be made to specialist teams at the click of a button. Body Map Image Within the ‘Activities of Daily Living’ tab, the full body image can be annotated using the toolbar directly above the image.
12	Once all tabs are fully completed, select the ‘Save’ button at the bottom right hand side of the document. If the document is partly completed and not finished, tick at the bottom left of the screen before selecting the ‘Save’ button (shown above). In the Documents tab, the document will show as ‘incomplete’.
13	Important Note: An ‘SCM Notice’ pop-up window will alert staff of any actions or additional information required prior to saving. For example, saving a document without completing all significant/mandatory fields. Staff are required to read the prompt and acknowledge or action as appropriate.