This guide is for all medical staff in inpatient wards. It provides an overview of completing the inpatient doctor ward round and progress note 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 Adult Ward

From the ‘Tracking Boards’ tab, choose an adult ward from ‘Department’ list and select the required admitted patient.

 

 

 

Note

Some frequently used inpatient documents are accessible from the quick launch documents shortcut option. Other documents not listed can be created by selecting the Enter Document icon on the main toolbar and searching for the document.

 

 

 

2

Select the arrow to the side of the ‘Quick Launch Docs’ button at the bottom of the screen, then choose ‘IP Doctor Ward Round and Progress Note’ from the list provided.

 

Alternatively, right mouse click on the patient, hover on ‘Quick Launch Documents’ and select ‘IP Doctor Ward Round and Progress Note’

 

Right mouse click action performed within an adult location/ward

 

 

3

Complete IP Doctor Ward Round and Progress Note

The ‘IP Doctor Ward Round and Progress Note’ consists of two tabs.

 

Note – VTE is now remaining on paper

 

This document will be completed by doctors for adult patients at intervals as required, following completion of the inpatient clerking document.

 

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 previously entered into other documents. 

 

  indicates mandatory and significant field/s needs to be completed. Icons disappear once all applicable fields on the section 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 all required tabs before saving the document.

 

4

Actions/Information bar

Action bars appear based on certain selections made within the document being completed. It prompts medical staff on actions to consider or take next. Use your clinical judgement to make appropriate decision.

 


 

 

5

Quick Actions buttons

There are action buttons within some tabs. For example:

 

  • Latest information completed elsewhere, eg observations, allergies or orders placed on Sunrise, can be inserted automatically using button below. It is recommended that the button is selected even if information is currently displayed to ensure the most up-to-date information is shown.  

 

  • Investigative requests including referrals can be made at a click of a button and the SpO2 target can be set using these buttons. 

           

 

6

Conditional Triggers

A question answered on the document could trigger additional questions to be answered. The additional questions might appear to the side or underneath the current question.

 

For example, if you tick the radio button for ‘DO NOT ATTEMPT Cardiopulmonary Resuscitation (DNACPR)…’, it will trigger an additional question underneath for you to complete

 

 

Note – If DNACPR – Do not attempt CPR is selected, please complete a DNA CPR Active Form on paper, if not completed yet and add it to the patient’s notes

 


 

 

7

Body Map Images

Within the ‘Doctors Ward Round’ section, 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.

 

8

Saving Document

Once all tabs are fully completed, select the ‘Save’ button. If the document is partly completed and not finished, tick  at the bottom of the screen before selecting the ‘Save’ button. The document will show as ‘incomplete’ on the Documents tab. 

 

9

SCM Notice

These appear as alert pop-ups. For example, saving a document where significant and/or mandatory field/s haven’t been completed. Read the prompt and acknowledge or action appropriately.

             

 

 

 

Title: Inpatient Doctor Ward Round and Progress Note

Author: Sunrise Training Team – EW

Date: 20/07/2021

Version:  v1.0