This guide is for all medical staff in inpatient wards. It provides an overview of completing the inpatient clinical clerking document for paediatric 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)

From the ‘Tracking Boards’ tab, choose an ED location from ‘Department’ list, then select appropriate view and desired admitted patient.

 

 

Patient Admitted in Paediatric Ward

From the ‘Tracking Boards’ tab, choose a paediatric ward from ‘Department’ list. Select appropriate view and select desired 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 on the toolbar and searching for the document.

 

 

2

Admitted in ED – Paediatric only

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

 

Select the ‘Enter Document’ icon from the main toolbar 

 

 

Open ‘Paediatric IP Clerking Document’ from the ‘Document Entry Worksheet’ dialogue window.

 

 

3

Admitted in Ward

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

 

Alternatively, right mouse click on the patient, hover on ‘Quick Launch Documents’ and select desired document to create.

 

Right mouse click action performed within a paediatric 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 from ED (Paediatric Patient) - 

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

 


 

 

4

Complete Paediatric IP Clinical Clerking Document

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

 

The Paediatric IP Clinical Clerking Document is an example of a ‘Structured Note Entry’ styled document on Sunrise. It’ll be completed by doctors for paediatric patients once admitted on the ward.

 

Currently selected tab is highlighted in white with 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 other previously completed document on patient’s record. 

 

  – indicates mandatory and significant field/s needs to be completed. Icon/s disappears 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.

 

5

Actions/Information bar

Action bars appears based on certain selection 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.

 


 

 

6

Quick Actions buttons

There are action buttons within some tabs to support and enhance staff experience whilst completing the clinical clerking document. For example – 

 

  • Referrals can be requested to other teams or specialty from within the document being created at a click of a button as illustrated below. See ‘QRG – Place a request for referral’ for more information.

 

  • Latest information completed on other aspect of a patient’s record i.e. observations completed can be inserted automatically using button below. It is recommended that the button is selected even if information is currently displayed.

 

 

7

Conditional Triggers

Occurs when a selection is made on a radio button option with ‘…’ at the end. A question answered on the document could trigger additional question/s to be answered by staff. The additional question/s might appear on the side or underneath the current question.

 

Example – ‘Former smoker…’ selection triggers other questions below.

 

Example – ‘Never smoked’ selection doesn’t trigger any question.

 

8

Assessment Scores

Some fields automatically calculate scores based on entries made. Scores recorded can be modified by making changes to selections or entries made.

 

9

Body Map Images

Within the ‘Review of Systems’ section, 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 to colleagues within the document tab that the document is in progress. 

 

11

SCM Notice

Appears as a pop-up alerting staff regarding information recorded or to act. For example, saving a document whilst significant and/or mandatory field/s haven’t been completed. Some examples are illustrated below. Staff are required to read the prompt and acknowledge or action appropriately.