MTW IT Service Desk

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 ‘Paediatric IP Nursing Admission’ document can be started as soon as the ‘Paediatric 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 ‘Paediatric 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, left click on the arrow on the ‘Quick Launch Doc(s)’ button and choose ‘Paediatric IP Nursing Admission’ from the list provided.

Alternatively, right click on the patient’s row on the Tracking Board and choose ‘Quick Launch Documents’ and then select ‘Paediatric 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 clicking on the ‘Enter Document’ icon in the main toolbar. 

3

The ‘Paediatric IP Nursing Admission’ document will open and should be completed by nursing staff for paediatric patients admitted to the ward.   There are several ‘tabs’ across the top of the screen, as shown below. 

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. Paediatric IP Clinical Clerking, ED Triage or ED Clinical Documentation.  

 – 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:  Nursing Assessment 

Displays a summary of pre-populated information completed by the medical staff within the Paediatric IP Clinical Clerking document.  Use the scroll bar on the right-hand side to view the information.  Complete all relevant sections of the document, including observations and pain assessment.

5

Tab:  Safeguarding 

Safeguarding information will be copied forward if it has been completed within the Paediatric IP Clerking document or ED Triage and ED Clinical Documentation document (if admitted from ED).  Information can be started, added or amended within this tab.     A flag will appear on the relevant ward Tracking Board if Safeguarding concerns are indicated. 

6

Tab:  CAMHS Risk Assessment   

CAMHS Risk Assessment can be completed within the ED Triage and ED Clinical Documentation (if patient admitted from ED) and will copy forward to this tab.   However, information can also be started, added or amended within this tab.     Alerts will be displayed depending on the tick boxes selected. 

7

Tab:  Infection Control Screening 

Can be completed within the ED Triage and ED Clinical Documentation (if patient 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, namely ‘Inpatient Infection Prevention and Control’ 

8

Nursing Admission Document – Key Points

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

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 question/s to be answered by staff. The additional question/s might appear on the side or underneath the current question.

Some fields automatically calculate scores based on information entered.  Total scores displayed can be recalculated by making changes to selections made initially on the document.

There are action buttons within tabs to aid staff when completing the nursing admission document. For example, certain investigative requests and/or referrals can be made at a click of a button as illustrated below.

Within the ‘Nursing Assessment’ tab, the body maps can be annotated using the toolbar directly above the image. 

9

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). This will indicate to colleagues within the ‘Documents’ tab that the document is in progress as demonstrated below. 

10

Important Note: A ‘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. 

Note:  A blue or red ‘star’ box will appear on the tabs to indicate if any mandatory or significant fields require completion prior to saving 

11

When saving the document, an alert message may appear.   Read the message and select the appropriate ‘Acknowledgement Comment’ from the dropdown list.   Click ‘Proceed’ on the bottom right-hand side to continue.