User Manual - the Yorkshire Neonatal Network
Contents
1. Details at birth Added comments At Bradford Teaching Foundation Tryst x reves Eregnandas Cranial Ultrasound Ad Hoc Eve nt Fo rms ial BadgerID 5PKV oie deh e Retobgy jis aie Labour Delivery Abdominal xRay Previously in the middle column of On this da e E Parents Blood CSF Urine culture F PaE Biochemical screening the main body of the baby s home Corr gest age is 32 weeks 5 days nay icci ROP screening No recorded weight A Admission a ti notes Working weight 835g 08 Nov z Admission details Kipala ate page Cannot calculate BAPM Care Level GP details Pr ER Cannot calculate HRG value CRIB II ane Management to this date fetal cbt 08 Nov 11 Daily seta not marked amp complete 1 Intensive care day k C ee R 09 Nov 11 Missing daily summary dai charts Not Ventilated E 10 Nov 11 Missing daily summary data E 11 Nov 11 Missing daily summary data Dal Data Fo rms vic a summary in stay to this Discharge 12 Nov 11 Missing daily summary data y Na E ENEA Discharge details 13 Nov 11 Missing daily summary data Previously at the top of the left No ROP a Adawi y Discharge letter E 14 Nov 11 Missing daily summary data No Blood o EAEn hE ay m 2 Year follow up m Today Missing daily summary data col umn of the malin body of the reports No Hearing Screen this stay Diagnosis to this date No diagnosis recorded Drdgqs to this date NoNtrugs recorded Me baby s ho2. Admission E E Admission details Congenital malformations E GP details E CRIB II E Newborn examination Admission Summary Centile Chart Diagnoses Notes The Newborn examination links to a separate form identical to the one of the same name in Badger3 The Admission Summary output link generates a printable eS Gp Audit trail I lt Previous Tab gt NextTab O Save amp Close o Cancel document essentially the same as the one from Badger3 The Centile chart generates a printable version of the Centile chart again the same as Badger3 Details at Birth and Admission T GVKQ9SPI31 RUBBLE Bambam Baby boy singleton born 08 Nov 2011 11 24 at 26 4 weeks weighing 820 grams Admitted 08 Noy 2011 12 32 From Bradford Teaching Foundation Trust Mow in unit day 39 of stay Today 16 Dec 11 Day 39 of life Corrected gestational age is 34 weeks 0 days Working weight 835 grms Baby Details Admission To Unik Admission to Unit Parent Details Date and Time Admitted 58 Moy 11 Y ati232 Pregnancy Details Admitted to Bradford Teaching Foundation Trust Labour and Delivery Admitted from adford Teaching Foundation Tru GP and Professionals Bradford Teaching Foundation Trust CRIE II E Admitted from this hospital Admission type Cannot Derive Detail Final Neonatal Outcome Admission Details Pri
3. Link back to The same as home page Badger3 The new homepage List of patients by rele various medical criteria UK Neonatal Patient Data Management Previously on the Previously National Neonatal Care Record System for the NHS throughout the UK Unit Reports Website available on the Data Quality tab Help User Guides Patient Selection AX Select exiting baby care ensode Select existing or sa Uther Badger et Patients Switch to Maternity system add new baby User Details BadgerNet News g j m User log in E Latest BadgerMet news j a al Service Desk Ma Login in to access Service Desk Service desk access h UK Neonatal Configuration Updates i 08 Now 11 Neonatal release notes 10 Oct 11 Neonatal release notes 19 Sep 11 Neonatal release notes TEST SYSTEMI SYSTEM Dect 1935 7 Select existing baby You can enter any text detail in the search box to search for patients First name Surname partial name NHS number Select existing or add new baby p Find existing baby care episode orjcreate a new baby episode of care E Default baby search Ca Currently admitted options ae E Now in unit p ee a E Temporary NHS Mur Ca Discharged Default Baby Search Other search Q Returned 3 results National ID E T KTUYAHZPX1 Mame DOB SMITH Toby 20 Oct il Jj Specific groups oe T 7NKGS4EX61 GOOGOO Baby 02 Dec 11 O
4. Ventilation CPAP No ventilation or CPAP Ventilation via ET tube tracheostomy wf CPAP Nasalventilation Added oxygen Flow device With CPAP Mode of ventilation Conventional HFOW Mode of CPAP nCPAP prong or mask Nasopharyngeal Airway in situ Yes No Nitric oxide Yes No ECMO today Yes No Significant apnoea today Ce No 1 Pneumothorax today Yes No Chest drain present Yes No Tracheostomy present No Acute Chronic Replogle tube in situ Yes No Surfactant given today Yes Total surfactant dose given today mg Daily comments Comments for discharge summary No Not including surfactant at resus There are still icons which you can click on for definition advice They will tell you in exactly which circumstances you should select yes for this data item Most of the tabs contain the same details questions as the form from Badger3 but with the addition of notes boxes The infection tab is slightly different partly in support of line associated infection audits You are now asked whether there is suspected sepsis or a confirmed diagnosis and whether treatment is being given for CoNS or other organisms The new haematological skin and other problems tabs have been added simply to allow free comment on these clinical areas There are no questions to be answered simply free text boxes General information Respiratory Cardiovascular Gast
5. separate free text box that allows you to add comments to the discharge letter Notes for discharge letter Echocardiograph e T GVKQ9SPI31 RUBBLE Bambam Baby boy singleton born 08 Noy 2011 11 24 at 26 4 weeks weighing 820 grams Admitted 08 Moy 2011 12 32 From Bradford Teaching Foundation Trust Mow in unit day 41 of stay Mote Entry Day 19 Dec 11 Day 42 of life Corrected gestational age is 34 weeks 3 days Working weight 635 grms New Form There is also a new form called Echocardiograph In fis dec this form there is a free text box for comments and a box to record Comments who performed the test and their designation Test carried out by a Designation There have been a few changes to the Daily Details form from Badger3 The obvious one is that now instead of one long form it has now been broken into sections which are split over different tabs displayed on the left hand side The first tab General Information includes the top part of the old form the location of care daily weight carer nursing and monitoring status etc In addition it now has two sections where you can record daily notes on any social issues and any parental communications You can also add a comment to the discharge letter for these areas Day Summary Daily Summary Data The layout of the daily details form has changed slightly in BadgerNet T GVKQ9SPI31 RUBBLE Bambam Bab
6. ventouse assisted Yes No No Yes Unknown 10 10 10 a m ta pa pa f po wad sa a wo uo ao oo 0 3 T 10 Yes No Unknown Time from birth to clamp mins secs Yes No Unknown mins El O Save amp Close B Cancel The fourth and fifth tabs Pregnancy Details and Labour and Delivery are essentially the same as the forms of the same names in Badger3 The sixth tab GP and Professionals is again the same as the GP Details form in Badger3 You can still select to search for the GP details from the GP Database the search box looks slightly different and now as well as being able to search by the surname or the postcode you can also search by any word in address such as a village or town name Details at Birth and Admission x E T GVKQ9SPI31 RUBBLE Bambam Baby boy singleton born 08 Now 2011 11 24 at 28 4 weeks weighing 820 grams Admitbed 08 Mow 2011 12 32 From Bradford Teaching Foundation Trust Mow in unit day 39 of stay Today 16 Dec 11 Day 39 of life Corrected gestational age is 34 weeks 0 days Working weight 835 grms Baby Details Admission To Unit Used to record the final outcome of any baby who has been transferred out from this unit or is still hospitalised at 1 year of age Parent Details Final Neonatal Unit Outcome Home Ward Died Unknown Pregnancy Details Final outcome notes Labour an
7. 2011 11 24 at 28 4 weeks weighing 820 grams Admitted 08 Noy 2011 12 32 from Bradford Teaching Foundation Trust Now in unit day 41 of stay Note Entry Day 19 Dec 11 Day 42 of life Corrected gestational age is 34 weeks 3 days Working weight 835 grms Added Comment Note date and time ERRRBBY st 11 57 Comment type Medica Nursing Daily care note The added notes facility was available in Badger3 and could most easily be found at the bottom of the list of Ad Hoc forms In the BadgerNet version added comments you can now specify whether the note is a medical Notes nursing or a daily care note and record the date and time of the note which was previously just recorded as today Radiology i f E T GVKQ9SPI31 RUBBLE Bambam Baby boy singleton born 08 Noy 2011 11 24 at 2844 weeks weighing 620 grams Admitted 08 Noy 2011 12 32 From Bradford Teaching Foundation Trust Now in unit day 41 of shay Mote Entry Day 19 Dec 11 Day 42 of life Corrected gestational age is 34 weeks 3 days Working weight 835 grms New Form There is a new Ad Hoc form called Radiology Date and time performed 19 Dec 11 at 11 55 available in BadgerNet In this form you can select to record details Investigationdone o o about other radiological examinations not covered previously Abdo Mets Xray USS and Cranial USS There is a pick list to select the examination and then a free text box for notes There is a
8. E T svkossPI31 RUBBLE Bambam 08 Nov 11 Admitted 05 Dec 11 02 Dec 11 08 Nov 11 If you chose to Select no baby the option to Create new baby care episode will appear on the home page underneath the select baby option Alternatively you can select Create new baby episode now from this search box this will open the same New Patient Care Episode Create new baby episode nov Select no baby bl Discharged Basic baby list parameters List parameters Care location All allowed 2 National Local ID Surname Forename DOB Range x to Admission Date Range to Discharge Date Range to Gestation at birth to weeks Birthweight Range to grams Resulting list Limit to 10 100 1000 10000 records Save amp Close fx Cancg By clicking on List Parameters List parameters Ea ar you can now select to search 32 1200 the patient list by your chose as criteria 28 620 L lancel y New Patient Care Episode New Neonatal Admission E xj This form is used to create a new i admission The key data required to lt 5 New Patient Care Episode i Select type of care episode and core baby details below create the admission are e NHS Number e Surname e Date amp Time of Admission New Care Episode Episode loca
9. Neurology Convuls Lines Line In Fluids and Feeding TPN Feeds If you click on a row in the Daily summary data chart you can also opt to view the data as Trend which plots a line across the days showing the change in values Reports tab The Reports tab allows you to view and print various out puts it is similar to the left hand menu of the home page on Badger3 You can print the admission summary centile chart and discharge letter from this view In addition you can now print two new features a sheet with all the social issue comments you ve recorded and one with all the parental communications you ve recorded Live Patient Reports jarc iived Repor lt 2 47 Admission Summary E a H d Lop bi F Fs L Canfi F eo AS a E E Confirm and save 7 Centile Chart Ena 47 Social Issues Child Protection Comments Bradford Teaching Foundation Trust Bradford Neonatology Duckworth Lane Broadford West Yorkshire BD A aj Parental Communications 4 Discharge Letter Summary of care to 19 Dec 201 1 Consultant No assigned consultant 19 December 201 1 Generated 19 December 20s i 7 24 RUBBLE Bambam NHS No T GVKQ9SPFI131 Baby boy singleton born 08 Nov 2011 11 24 at 26 4 weeks weighing 620 grams Admitted 08 Nov 2011 12 32 from Bradford Teaching Foyfdation Trust Local unit id RAE1234569 Now in unit day 42 of stay reports Another new opt
10. arate form Details at Birth and Admission Baby boy singleton born 08 Noy 2011 11 24 at 26 4 weeks weighing 820 grams E T GVKQ9SPI31 RUBBLE Bambam Admitted 08 Mow 2011 12 32 From Bradford Teaching Foundation Trust Mow in unit day 39 of stay Today 16 Dec 11 Day 39 of life Corrected gestational age is 34 weeks 0 days Working weight 835 grms Baby Details Labour Admission To Unit Parent Details Pregnancy Details Labour and Delivery GP and Professionals RIE II Final Neonatal Outcome Delivery Resuscitation Onset of labour Meconium Stained Liquor Labour history Drugs in Labour Date and Time Membranes Ruptured Duration of Membrane Rupture Maternal pyrexia in labour more than 38C Intrapartum antibiotics given Presentation Immediately Before Deliwery Mode of Delivery Baby delivered in water Condition at birth Offensive liquor Apgar Score at 1 min Apgar Score at 5mins Apgar Score at 10mins Apgar Score at 20mins Was cord camping immediate Stripping of blood from cord Resuscitation Staff present at resuscitation Firstaaso 5 Ga Audit trail Previous Tab 3 Next Tab at Hours No Yes Unknown No Yes Emergency caesarean not in labour Emergency caesarean in labour Elective section not in labour Elective section in labour Vaginal forceps assisted Vaginal spontaneous Vaginal
11. b gives the full list of data quality errors for the baby just like the summary on the home page allowing you to link to the missing data eaennaTta mT anrmiigecrn ie a Ou uu L old LI 12 3 Poe ie Notes tab The Notes tab located underneath the Start tab is very similar to the Patient data tab in Badger3 The Daily summary tab at the top presents the daily data as if you had click on Daily data at the bottom of the left hand menu on the Patient data tab in Badger3 ull Notes View ad 18 Dec 1 1 Clinical Summary ai notes for day ie Daily Summary fy x Summary for Sunday 18 Dec 11 epeei i D S and 2 a Ve HIHI i Uren sore Shee gt At Prado i Teaching Foundation Trust ay oummary 13 Dee 11 16 31 r On this date General information Tue Wed Thu Fri Sat Sun Day 41 of life i 1 2 3 4 Corr gest age is 34 weeks z days ae ae ate ec E T 5 J 10 11 eg econ ae 18 Dec Care locn MNU orking Welg g ec as 13 14 15 16 17 18 BAPM Care level High Dependency Reduced Form For TE or ee whole input For 20 2 22 23 Ad 25 HRG 2 data z Working wt 635 grams e 28 2 al F Management to this date Carer Status Carer resident Not caring For baby 1 Intensive care day ObsiMon Continuous 5 1 High dependency day Transported Mot transported Daily summary data forms Not Ventilated re charts 7 H z E eee ee ree Parental Communications Daily care summary for 18 Dec 11 reening sum
12. d Delivery GP and Professionals RIB II The seventh tab CRIB Il is a simple form where you can enter the details Temp amp worst base excess to calculate the CRIB II score if you wish Final Neonatal Qubcome lt lt Previ Tab Previous Tal The eighth tab Final Neonatal Outcome is the same final outcome selection previously featured in the Baby Details form In addition there is now a free text box where you can add outcome notes E p Audit trail Previous Tab gt Next Tab O Save amp Close x Cancel Discharge E Discharge details Discharge letter E Year Follow up The Discharge details form now has three tabs Tab one Discharge details includes basic discharge info such as date time and discharge destination and the general milk weight oxygen follow up details etc that were located in the middle of the discharge form on Badger3 Discharge Details The Discharge letter printable output is currently identical to that in Badger3 and is generated from the Discharge details link previously General Discharge details listed in the episodic forms on Badger3 Details at Discharge Summary of stay details and discharge information l D j g T GVKQ9SPI31 RUBBLE Bambam Baby boy singleton born 08 Nov 2011 11 24 at 28 4 weeks weighing 820 grams Admis 0s Mov 2011 12 32 From Bradford Teaching Foundation Trust Now in unit day 39 of
13. ee NHS Number RENITESIE E Verified several tabs on it In the old system these forms were ara Doce TE Create temporary NHS Number separately listed under Baby and parents Labour and Delivery Baby s LocalHospital ID RAE1234569 i Bad ID Pregnancy and delivery and the first episodic forms eo SS oenen CRIB II such as Admission details r G Final Neonatal Outcome Other Previous Surnames Sex Female Male Indeterminate Non NHS patient Yes Overseas patients only DO NOT use for UK residents The Baby Details tab first in the list contains the General Baby Details elements such as demographics and basic birth details such as gestation There is also a new Congenital malformations section with two boxes the first box labelled Diagnoses uses the same pick list search facility present in the Badger3 system where you can click on diagnoses to generate a list The second box labelled Notes is free text for additional information General information Birth Order A of fa Date and Time of Birth 08 Nov 11 at 11 24 Place of birth E Place of birthis this hospital Birth Location Agreed gestation at birth 28 j Weeks 4 Days Birth weight 820 grams Between 5 and 10 centile Head Circumference at Birth cm Length at Birth cm Baby s blood group Vitamin K given Route of administration of vitaminK
14. he data is collected through the other main clinical forms Details at Birth and Admission i i Things to do The data quality checks that were in the left hand column of the baby s home page on PE E ee adinissen Badger3 are now at the bottom of the page There are two standard categories of checks nap Things to do and NNAP The missing details are listed under a heading of which form they are in and as with Badger3 if you click on the problem it takes you directly to where the data must be entered Mother s MHS Number 6 Intended place of delivery Temperature value 9 Parents seen by senior staff Ad Hoc and Daily Details forms r During stay ES E 4dded comments E Cranial Ultrasound E Radiology E Abdominal sRay E Blood CSF Urine culture Ad Hoc Forms as on Badger3 New or amended Ad Hoc forms E Biochemical screening E ROP screening m Immunisations Oo E Hearing test E Echocardiograph Daily summary data E 08 Now 11 Daily data not marked as complete B09 Noy 11 Missing daily summary data Blood spot form as on Badgers E 10 Nov 11 Missing daily summary data E 1 Nov 11 Missing daily summary data fae 1 r je n i Hai E Ta He Badgers s Daily Details form is now called Daily Summary data E 14 Nov 11 Missing daily summary data E Today Missing daily summary data New forms Added notes T GVKQ9SPI31 RUBBLE Bambam Baby boy singleton born 08 Nov
15. ion is the Confirm and Save button You can opt to save a copy of any of these reports at any stage of the episode when you do this a static copy of the report to date will be created and stored in the Archived Reports tab If you have any system queries contact Lauren Cottrell Network Data Manager 01274 364920 or lauren cottrell bthft nhs uk
16. is essentially the Clinical Summary of Stay form but with the addition of the Principle Principal Diagnoses Problems and Procedures section and the free text GP summary section from the discharge details on Badger3 Active Problems at Discharge Notes Treatments Procedures during stay Principal Procedures Respiratory summary Diagnoses a Gp Audit trail lt C Previous Tab gt NextTab Save amp Close Cancel Baby boy singleton born 08 Nov 2011 11 24 at 28 4 weeks weighing 820 grams Admitted 08 Nov 2011 12 32 From Bradford Teaching Foundation Trust Now in unit day 39 of stay Today 16 Dec 11 Day 39 of life Corrected gestational age is 34 weeks 0 days Working weight 835 grms E T GVKQ9SPI31 RUBBLE Bambam Discharge details Tab three Discharge Diagnoses Discharge letter details Key diagnoses for audit ya Discharge Diagnoses VON Based on the attached definitions see did the baby have these diagnoses during this admission only VON ISa yes no tick list of Key i Meconium Aspiration Syndrome No Yes Unknown diagnoses for the Vermont Oxford Respiratory Distress Syndrome No Unknown Networ k Transient tachypnoea of the newborn TTN Unknown Patient Ductus Arteriousus Unknown Necrotising Enterocolitis Unknown Focal Gastrointestinal Perforation Unknown Hypoxicischaemic encephalopathy Unk
17. mary In stay To This dare Daily comments Test comment in Parental comms o Ultrasound this stay Neurology NAS Common events o ROP Screening done to date this stay Tone Normal E Added comments Ne Blood spot Screen this stay Consciousness Normal reports E Cranial Ulkrasqund No Nearing Screen this stay E Radiology Diaqnysis to this date 19 Dec 11 11 30 i Lauren Cottrell E Abdominal XR d i i Radiology 19 Dec 11 16 32 ominal Ray No diagnosis recorded E Blood CSF Urine culture When 18 Dec 11 at 11 30 Drugs to this date Investigation done Hip ultrasound E Biochemical screening No drugs recorded Notes erudszg rslyfgrey E ROP screening E Tmmunisatians E Hearing test E Echocardiograph Here you can view the right hand summary presented in any daily summary data form Simply select the date you wish to view using the calendar and the summary will be presented You can also add any ad hoc event forms or re open the Daily summary by clicking on in the middle while any additional notes free text or ad You can re open any of these hoc forms will be displayed on the right hand side forms for amendments by clicking on them here the links listed under common events notes charts Tal reports The Full Notes View allows you to see all forms completed for the admission instead of just forms for specific days Daily Summary y al Decem Full Hotes View Mon Tue Wed Thu Fr Sat Sun Dail
18. me page E Research projects amp S National Neonatal Audit NNAP Episodic Form The basic care summary that used to be on the left hand side of the home page is now located here There is no longer a graphic representation Data Quality Check Lists D Things to do Details at Birth and Admission Place of birth Previously located in the left hand NNAP i i Intended place of delivery col umn of the main body of the ba by s SP Postcode Day Summary Forms home page 08 Nov 11 Daily data not markers Key details Key events during stay lt p Reminders Admitted to unit 08 Nov 11 at 12 32 E No ROP Screening done during this stay E Update todays daily summary Today Day 30 of life Corr gest age is 32 weeks 5 days ROP Screening due E Episode 1 of 1 Details at Birth ge betel at birth Details at Birth and Admission xi a Details at birth T GVKQ9SPI31 RUBBLE Bambam E Previous Pregnancies i Baby boy singleton born 08 Nov 2011 11 24 at 28 4 weeks weighing 820 grams E Pregnancy Admitted 08 Noy 2011 12 32 from Bradford Teaching Foundation Trust Now in unit day 39 of stay Today 16 Dec 11 Day 39 of life Corrected gestational age is 34 weeks 0 days Working weight 835 grms E Labour Delivery E Parents Baby Details Admission To Unit Baby s Identification The links in these lists now open one form with
19. mp select box operations or procedures today another search amp select box and investigations today such as cultures taken radiology done etc also a search amp select box Other start tabs Under the basic baby summary you ll see there are three tab options the first default tab is the Baby Home Page but next to this are two other tabs Data Quality Checks and Care Episode History Baby Home Page Data Quality Checks Care Episode History 1 ae Patient journey for T GVKQ9SPI31 start Fi Create yew baby care episode 08 Nov 11 Bradford Teaching Foundation Trust Neonata 1 L TE y TI now piewing RUBBLE a_i a ki Tenne care day a eat in ae day 42 of stay Admitted 08 Nov 11 at 12 32 E Not Ventilated y View discharge letter From Bradford Teaching Foundation No diagnosis recorded Trust a No drugs recorded BadgerNet ID SPKV a No ROP Screening done to date this m Hospital ID RAE1234569 stay reports The Care Episode History displays the list in order of episodes for the baby It presents a basic summary under the three headings of Admission During stay and Discharge So if a baby was transferred from Airedale to Bradford to Leeds and back to Airedale all four episodes would be displayed in the list with a basic summary very similar to the summary presented in the left hand menu of the home page on Badger3 The Data Quality Checks ta
20. ncipal category of admission Neonatal intensive care Admissionweight grams Centile Get birth weight Admission Head Circumference cms Centile Get birth head circ Temperature measured after admission Yes No Unknown When recorded Temperature value p Temperature not recordable Yes outside range of thermometer BF on admission mmHg Mean blood pressure HR on admission per min Resp rate on admission per min S a02 on admission Blood glucose on admission mmol L Parents seen by senior staff Yes No Unknown Time first seen Time first seen Principal Clinical Reasonfor admission pre kai reterm Froblems onadmission Lead consultant Others consultants z Admission notes Ga Audit trail E Previous Tab gt Next Tab Neonatal Network C 3 Code RAEO S Cod e RAEO Y at l O Save amp Close rx Cancel The second tab Admission to Unit holds most of the fields previously found on the Admission details form on Badger3 This is the tab where you record the obs at admission including the all important temp on admission As before you can list the key reasons for admission and make free text admission notes The third tab Parent details is the same as the parent details form on Badger3 except with the addition of the number of previous pregnancies question which used to be on a sep
21. nown Periventricular leucomalacia Unknown Two Year Follow Up Also listed in the discharge section is the 2 year follow up form This form cannot be populated until the baby is at least 1 year old if you open it early it will present a warning explaining this The form includes various sections for assessment covering the same details as on the 2yr follow up form in Badger3 Year follow up ae x Assessment Meuromotor Malformations Social Respiratory CYS system Gastro intestinal Tract Renal Neurology n Cannot edit input Form data x Growth All fields tn this form blocked until the baby ts more than one Development score year old Bailey IIT ok Griffiths Schedule of growing Auditory ision Communication Neurological diagnosis Jo Audit trail Save amp Close x Cancel Audit Me The Research projects link within the Audit section opens a form E Research projects lt where you can record details of any studies the baby has been a8 Mational Neonatal Audit enrolled in This was previously at the bottom of the Clinical Summary of Stay form in Badger3 Research projects Research medication Enrolled in study Baby received study drugs The National Neonatal Audit link opens the NNAP episodic form which is the same as in Badger3 including the recent update that has made it a largely read only form because t
22. ord Teaching FoundatioN Trus On this date Day 42 of life Corr gest age is 34 weeks 3 days No recorded weight Working weight 835g 08 Nay Cannot calculate BAPM Care Level Cannot calculate HRG value Management to this date 1 Intensive care day Not Ventilated Screening summary in stay to this date No Ultrasound this stay No ROP Screening done to date this stay No Blood Spot Screen this stay No Hearing Screen this stay Diagnosis to this date No diagnosis recorded rugs to this date o drugs recorded Not transported Social Issues Child Protection Daily comments Comments for discharge summary 7 al G Audit trail f Previous Tab 3 Next Tab You can also navigate between tabs using these buttons r FA Save amp Cl jse x Cancel An overview of the data you ve entered for the day will be displayed here You can navigate between tabs by clicking on the names of the tabs on the left side The second tab Respiratory contains the details relating to respiratory support complications etc mostly the same as the section in Badger3 Again you can make daily notes or add comments to the discharge letter General information Respiratory Cardiovascular Gastrointestinal Neurology i NAS Ophthalmology Infections Metabolic Jaundice Haematological RenalfGenitourinary Skin Fluids and Feeding Other Problems Diagnosis Procedures and Drugs
23. rointestinal Neurology i NAS Ophthalmology Infections Metabolic Jaundice Haematological Renal Genitourinary Skin Fluids and Feeding Other Problerns Diagnosis Procedures and Drugs Diagnosis Suspectedsepsis Bacterial sepsis septicaemia Gram ve Bacterial sepsis septicaemia Gram ve Meningitis bacterial Fungal infection Treatment for suspected confirmed infection Coagulase negative staphylococci Organisms other than CoNS Daily comments Comments for discharge summary The Renal tab has been added to ask whether there is a urinary catheter present this is due to the BAPM 2011 care levels having this as a criteria Daily comments Comments for discharge summary K General information Respiratory Fluids and feeding aren nectar Parenteral nutrition today TPN Den Gastrointestinal IV glucose and electrolyte solutions ves No gt lt O Enteral feeds today Neurology i MAS XX _ r A Method of feeding Ophthalmolo EEE E BLL 5 ati Additives x Infections i Metabolic Jaundice Lines Line in situ today Haematological Renal Genitourinary Transfu sj ons Skin Full exchange transfusion today Yes No Fluids and Feeding Partial dilutional exchange transfusion Yes No today Other Problems Blood products today Diagnosis Procedures and Drugs Daily comments Comments for discharge summary ee The Fluids and feeding tab no
24. stay Today 16 Oxi 1 Day 39 of life Corrected gestational age is 34 weeks 0 days Working weight 835 grms Discharge details Discharge letter details Discharge Discharge Diagnoses WON Date and Time of discharged or death Populate discharge data from details during stay Discharge to Data at time of Discharge Discharge Address Discharge Postcode Weight grams Length cms Head Circumference cms Milk at Discharge Enteral Feeding at Discharge fe Received own mothers milk during this admission Yes No Unknown Notapplicable Feeding Notes Oxygen at Discharge Yes No Apnoea Cardiorespiratory Saturation Monitoring at Discharge Yes No Drugs at Discharge El E E Audit trail l F Previous Tab gt Next Tab ga Save amp Close l fx Cancel Details at Discharge Summary of stay details and discharge information xj B T GVKQ9SPI31 RUBBLE Bambam Baby boy singleton born 08 Nov 2011 11 24 at 28 4 weeks weighing 820 grams Admitted 08 Noy 2011 12 32 from Bradford Teaching Foundation Trust Now in unit day 39 of stay Today 16 Dec 11 Day 39 of life Corrected gestational age is 34 weeks 0 days Working weight 835 grms Discharge details Discharge letter details Principal Problems Treatments and procedures B Get discharge summary items from data collected during stay Discharge Diagnoses YON Tab two Discharge letter details
25. tion Default Trust name bel Episodetype Neonatal UnitAdmission hai Patient Essential Details NHS CHI Number f OE Create temporary National ID Baby s Local Hospital Clinic Episode D Forename Sex Female Male Indeterminate Date and Time of Birth at Birth Order of You have the option to enter other m te key data at the point of creating the Working Gestation Weeks Days Win bestia new admission such as basic birth Birthweigh grams n details formally found in the Neonatal Unit Admission General Baby Details form and Admission time at principle admission details formally x found in the Admission details form Admitted from E Admitted from this hospital Principal category of admission sr Principal Clinical Reasonfor admission E O Save amp Close fx Cancel Basic baby summary Previously in the left hand menu of the baby s home page S Patient Gay T GVKQ9SPI31 RUBBLE Bambam r S Baby boy singleton born 08 Noy 2011 11 24 at 28 4 weeks weighing 820 grams Admitted 08 Noy 2011 12 32 from Bradford Teaching Foundation Trust Now in unit day 30 of stay Baby Home Page Data Quality Unit Reports Library Help Unit Daily Update Baby Home Page Data Quality Checks Care Episode History 1 a gilo al Summary _ Details at birth During stay a
26. w contains several sections from the previous version of the form Here you must record the feeding and fluids of the day the lines in situ and any transfusions that have taken place The categories in these areas are the same and you can still pick multiple options where relevant the difference is that now they are all drop lists If you select other method of feeding now you cannot enter a free text description it is vital that if the baby is receiving any form of tube feeding you do not simply select other as this will not count towards your care level calculation General information Respiratory Diagnoses Cardiovascular Gastrointestinal Neurology MAS Ophthalmology Include yesterday s diagnoses Teese Gne Ongoing managementissues today f Metabolic Jaundice Haematological Operations Procedures today Renal Genitourinary Skin Fluids and Feeding ee Other Problems ae P roceoUrEs Drugs given today Get Yesterday s Drugs IV drugs given today Dyes no Drug Infusion T Comments for discharge summary fn H The Diagnosis Procedures and Drugs tab contains the drugs today section from the old version of the form still with a search and select box and pull through from yesterday but you can also select any infusions being given from a drop list In addition there are new sections to record diagnoses to date this is a search amp select box on going management issues such as tube feeding lines etc also a search a
27. y boy singleton born 08 Nov 2011 11 24 at 26 4 weeks weighing 620 grams Admitted 08 Noy 2011 12 32 From Bradford Teaching Foundation Trust Now in unit day 42 of shay Mote Entry Day 19 Dec 11 Day 42 of life Corrected gestational age is 34 weeks 3 days Working weight 635 grms General information rdiovascular Gastrointestinal Neurology i MAS Ophthalmology Infections Metabolic Jaundice Haematological Fenalaenitourinary Skin Fluids and Feeding Other Problems Diagnosis Procedures and Drugs General Details Patient care date 19 Dec 11 Location of care today NNU B TransCare PN ward Other obstetric area Weighttoday Working weight grams Get latest weight grams complete only if baby actually weighed today Most recent head circumference cm Most recent length cm Requiring 1 1 nursing today Yes No sick unstable Carer Status Carer resident Caring for baby E Carer resident Not caring for baby Carer not resident Nursing Status Barrier nursed Isolation Observations Monitoing None Continuous Special Obs at regular intervals 7 Other specialty reviewtoday Yes No No i Transportedtoday With Nurse Only Any major surgery today Yes With Nurse and Doctor With Paramedic To sign a day off now you must click on the flag which will then turn green All incomplete fields will then default to No None etc Zummary for Monday 19 Dec t Bradf
28. y summaries Opthalmology Tests f Screening Immunisations Scans Ray Ultrasound Abdominal Ray General comments J 10 Dec 11 00 00 10 Dec 2011 Day 33 of life Radiology when 10 Dec 11 at 00 00 5 E f E J 11 Investigation done CT scan of head Motes Test Radiology Form 12 13 714 15 16 17 18 18 Dec 2011 20 2 JA 20 F gA F Day 41 of life 25 f 0 wo cal J 1S Cher ay oc 18 Dec 11 11 30 Radiology When 18 Dec 11 ab11 30 Investigation done Hip ultrasound Filter Motes erudszg rslyfgrw C Show all A useful feature is the filter box which allows you to select which types of forms you wish to view Radiology in the example This would allow you to see all RoP forms completed by clicking Ophthalmology for example Again you can re open and edit any forms by clicking on them in the main screen Lau 19 Du Lau 19 Du Charts tab On the charts tab the user can access the Centile chart and a sequential data summary chart The Daily summary data chart lists the data recorded on a day to day basis for various fields and allows you to compare them easily Charts Pa N HA Daily summary data General Information 4 Centile Chart Date sate Weight aS eee Ty Add new Day Summary at 00 00 08 Dec 11 Lengti View as Trend Respiration Resp Support Added Oxygen Mode Vent Cardiovascular Pulm Vasodilator Inotropes reports Transfusions Full Exch Trans Blood
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