The Barts Heart Centre Millennium User Guide
Contents
1. Clinical Notes Print 2 1 minutes ago Patient Information 2 c amp ES r aX S a 8 Inpatient Summary Outpatient Summary al 5 EE PETET i gt i i Modify Documen ST LISTER 9678403 oO x x When you are finished Chart Review a Pa Allergies a Add H Type General Clinical Note Author Cockerill Elisabeth Anne _ M G se ect sign Problems and Diagnos ea Date 07042015 EE o esT Status Auth Verified Procedures and Diagn H E Subject Cardiology Clinic Dr Wragg Histories Fs ma Requests WF Ada P Associated Clinical Staff Modify Activity List PatientLevel Document 7 Results Review Form Browser fo jaAa eles BUZIS E Sloe o Clinical Notes ry Documentation F Add Final Report Pregnancy SF Add test for general clinical note Appointments View Pregnancy Summary Insert Addendum Here bad 4 B gt ae Action Performed 8 Proxy Clinical Staff RequestedBy R a Perform Cockerill Elisabeth Anne O7 Apr 15 15 10 BST Completed o a a cm Sign 4 gt a Ju Tipe Action Performed B Performed Date Proxy Clinical Staff Regu C By Status Perform Cockerill Elisabeth Anne O7 Apr 15 15 10 BST Completed By Date Sign Cockerill Elisabeth Anne O7 Apr 15 15 10 BST Completed Deen VERIFY Cockerill Elisabeth Anne O7 Apr 15 15 10 BST Completed By Encounter i LCO9PROD 321686208034 08 April 2015 12 14 BST 12 14 Page 20 The docu2. Procedures and Diagn pril 2015 12 17 BST Verified Histories I McDonnell Andrea Requests F Add 5 McDonnell Gayle Activity List McGeary Caroline Louise E Nash Jonathan I Openshaw Ann Marie Soni Rashmi Result title Cardiology Clinic Dr Wragg Performed by Cockerill Elisabeth Anne on O April 2015 16 10 BST Verified by Cockerill Elisabeth Anne on O April 2015 15 10 BST Results Review Form Browser cinieai otes Documentation F Add Pregnancy F Add Appointments View Pregnancy Summary E By Tope Action Performed B Performed Date Action Status _ Comment _ Proxy Clinical Staff Regu C By Status Perform Cockerill Elisabeth Anne O7 Apr 15 15 10 BST Completed C By Date pr 15 15 10 BST Completed pr 15 15 10 BST Completed Performed By pvi51217BST Completed By Encounter eeepc ee tea 151217BST Completed Ries LCOSPROD 321686208034 08 April 2015 12 22 BST 12 22 20 09 NR je i 08 04 2015 Page 21 5 5 Correspondence will be dictated via G2 speech and letters will be transcribed and stored in EPR e All results will be viewable in Millennium supported by EPR hyperlink e All images will be viewable via PACS hyperlink 6 Outpatient Documentation Nurses Page 22 6 1 Entering Height and Weight Click on Adhoc Recording Select Vital Signs Adult and Record Click in Weight Measured and record actual weight
3. PP I thc Meutrophil Alkalne Phosphatase Aetculocyte Count Wiecosity Plasma Full Blood Count i Menu 2 66 Inpatient Summary Seas Ambulatory Summary Pl Orders for Signature S Patient Information eee 23 Jul 2013 13 44 Specimen Blood Priority Collect Now Routine Lab Collec Chart Review BST Allergies P add Problems and Diagnoses p Routine 1 month Procedures and Diagnoses x Details for Full Blood Count FBC Histories Requests EAD Details i Order Comments G Diagnosis x Activity List Results Review Order details 5 Detail values Form Browser fesvorrania ieda e Eu 2013 ma Clinical Notes Specimen type Blood g r Collection priorit Collect Now Routine Lab Lg July Mo Tu We Th Documentation No Da o od JE Pregnant Y N Unascertained ue te ee iview E BS er a Copy to GP No Appointments Alternative label printer 15 16 17 18 Pregnancy Summary 22 23 24 25 23 3 H I 2 BG Newborn Summary Sign LI Full Blood Count Processing Bleep Tel No 1243 Priority Collect now Routine Malarial Parasite Processing Bleep Tel No 1243 Priority Collect now Routine Screening O Urea and Electrolytes Processing Bleep Tel No 1243 Priority Collect now Routine E Antibody Screen Site 1 Completed Priority AT O8 Jul 11 17 03 00 BST Collect dtm ia ce int 34 minutes ago Full Blood Court FBC SIE Rotna 26 Feb 08 11 03 00 GMT Pint lab
4. x Cl l C k O n Ad h O C Task Edit View Patient Record Links Notifications Index Documents Help Patient List Message Centre Qt Home E Scheduling Cy B Q EPR 4 RE Tear Off EY Attach exit FEE agement Office A Recent z Name ba Re CO rd l n g 4 Ad Hoc Recording ZZZTEST LISTER Lai Ed Adult Inpatient L E Dementia Screening Adult Admission Assess E NIH Stroke Score A amp Adult SafeGuarding L B Pressure Ulcer Skinn Bundle S Print SO minutes ago Patient Information a m L E urinary Catheter Insertion ult Risk Assessments M E Urinary Catheter Maintenance Inpatient Summary Y s Adult Discharge Check E Urinary Catheter Mainte E Outpatient Summary amp Doctor s IC B Vital Signs Adult Select Vital Signs Overview OAP a I D Vaal Signe Pact Chart Review H L B Waterlow Score Dementia Allergies F add Psychiatry cea Respiratory Care and Rehabilta Problems and Diagnos Maternity a Pianale Checklist Ad u It a n d R e CO rd A Emergency Department T E Urinalysis Procedures and Diagn E i amp Hepatology Histories T0 Requests Add Surgery Activity List Allltems Results Review Form Browser Clinical Notes Documentation SF Add Pregnancy F Add Appointments View Pregnancy Summary t gt Close xl By lye Performed B Performed Date Proxy Clinical Staff Request Commen By Status C By Date C Performed By By Encounter i i LCOSPROD 321686208034 30 Ma
5. Click in Height Measured and record actual This automatically creates and records the BMI Click on the Tick to sign 4 ZZZTEST LISTER 9678403 Opened by Cockerill Elisabeth Anne O zjx Task Edit View Patient Record Links Notifications Index Documents Help amp Patient List Message Centre t Home E Scheduling amp E i Q EPR 4 TE Tear Off FEY Attach Mp exit FEE agement Office R Recent gt Name amp 4 Ad Hoc Recording ZZZTEST LISTER _ to fx Menu q Adult Inpatient Adult Admission Assess L E Dementia Screening T E NIH Stroke Score Adult SafeGuarding TC B Pressure Ulcer Skinn Bundle SH Print 0 minutes ago Patient Information Fa poy a L E Urinary Catheter Insertion ult Risk Assessments 1T E Urinary Catheter Maintenance mia niai Adult Discharge Check M E Urinary Catheter Mainte S Aea L _ amp Doctors I B Vital Signs Adult m Overview i a hu I E Vital Signs Paeds Chart Review Spahr TC B Waterlow Score Allergies a dd E Psychiatry 5 Ana Rehabilital Problems and Diagnos Matemity B ESEA F Emergency Department T E Urinalysis Procedures and Diagn amp Hepatology Histories T0 Requests F Add Surgery Activity List Allltems Results Review Form Browser Clinical Notes Documentation SF Add Pregnancy 4F Add Appointments View Pregnancy Summary gt Close fa By Type Action ss Per
6. up 3 Weekend plan Page 26 Appendix 3 Autotext to be created for Thoracic Ward Rounds WR Lead Date Time Operation Day X post XXXXXX Significant comorbidities and issues Patient well unwell details Labs Significant CXR findings Significant blood results Pain control Modality Epidural PVB PCA Oral Pain Score at rest 10 Able Unable to cough effectively Mobilised Not mobilized Observations Temperature HR SR AF BP Saturation Oxygen requirement Drains Apical X mls XX suction airleak intermittent on cough on expiration continuous Basal X mls XX suction airleak intermittent on cough on expiration continuous XX X mls XX suction airleak intermittent on cough on expiration continuous Medications review VTE prophylaxis Analgesia Nebulisers Laxatives Antibiotics Drug Indication Day Culture results Plan Drains Leave on suction Off suction Drain out Other Imaging portable ward CXR Antibiotics Bloods Discharge planning When TTAs Others changes and plans Page 27 Appendix 4 Autotext to be created for Cardiac Ward Rounds WR Lead Date Time Operation Day X post XXXXXX Significant comorbidities and issues Patient well unwell details Labs Significant CXR findings Significant blood results Observations Temperature HR Rhythm Pacing BP Saturation Oxygen requirement Weight difference Wo
7. your entry so that you can amend it later How to modify pre existing entries t z ZZZTEST LISTER ened by erill Elisabeth Anne Task Edit View Patient Record Links Notifications Index Documents Help 4 Patient List Message Centre Q Horne ES Scheduling i amp Q EPR Zl E Tear Off ohn Attach H Exit ai AdHoc amp PM Conversation L Communicate z Access Management Office Once within the patient s record see above steps 1 8 Click on Clinical notes on the mems left hand side of screen select Owe a A EG 66 x B al P Clinical Documents 29 Risk Assessments Patient Information Inpatient Summary Last 500 Documents 47 out of 48 documents are accessible Document Count i For Ward Round Chart Review l i WR Initial the document you wish to COO y EE ER a Maa WR Clinical lead 0965 1 i Procedures and Diagn E Assessment and Progress Notes Summary of presenting complaint modify and left click on the ee j y of presenting comp 25 ICU Transfer Summary Requests F Add General Clinical Note Modify icon OT Results Rewiew Handover Note amp 5 Surgery Perioperative Record I Emergency Department Documents Cardiology EJ 14 Apr 15 11 41 BST Cockerill Elisabeth Anne Dr WE 14 Apr 15 12 33 BST Cockerill Elisabeth Anne IP WW
8. 015 13 06 BST Form Browser Merified by Cockerill Elisabeth Anne on 08 April 2015 13 06 BST Documentation F Add Pregnancy add Appointments View Pregnancy Summary z Request Comment C By Status Perform Cockerill Elisabeth Anne 08 4pr 15 13 06 BST Completed C By Date Sign Cockerill Elisabeth Anne 08 4pr 15 13 06 BST Completed iml VERIFY Cockerill Elisabeth Anne 08 4pr 15 13 06 BST Completed Sign Cockerill Elisabeth Anne 08 Apr 15 13 07 BST Completed By Encounter Modify Cockerill Elisabeth Anne 08 A4pr 15 13 07 BST Completed 4 LCOSPROD 321686208034 08 April 2015 13 07 BST mas 13 07 z oA te amp eo i x E OM ae Pr IO 08 04 2015 Task Edit Wiew Patient Record Links Notifications Index Documents Help Patient List Message Centre f Home Scheduling E i Q EPR Be E Tear Off E Attach Ml Exit H AdHoc amp PM Conversation Communicate Access Management Office List a gt Recent z Name Clinical Notes a XBRE Last 500 Documents 43 out of 44 documents are accessible Document Count Patient Information S6 B Inpatient Summary Outpatient Summary Overview Adu Nyarko George a Chart Review Cockerill Elisabeth Anne Final Report Allergies F agg Consultant TWO CsTestPROD Document Contains Addenda 25 Goldie Boyd map Gutteridge C Kooner Paul Problems and Diagnos
9. 1 SNOMED CT Finding F avourl t es fo d erg ic k Ad d t O Acute haemorrhagic gastritis 481682019 SNOMED CT Finding Acute neutrophilic gastritis 953275014 SNOMED CT Finding F avourites Acute on chronic gastritis 1785555010 SNOMED CT Finding AG Atrophic gastritis 506116018 SNOMED CT Finding 4525015 SNOMED CT Finding Alcoholic gastritis C IC k O K s Alkaline reflux gastritis 502298012 SNOMED CT Finding Set filter to contains to return To view Favourites folders click ee Responstie ical Sa SDAT Senile dementia Alzheimer s type l T Free Text ANICirical Prac Access 02 T on Favourites b utton Display As At Age Onset Date Comments a a Confirmation Classification Status Cancel Reason fCorfimed Active Ranking Resolved At ge Resolved D ale h gt Show Additional Details Fie to Past Medical History OK OKkAddNewi Add Problem t Diagnosis abl Home i Fayouites 7 Fale Folder Favourites Page 16 Any folder can be set as your i Up fa Home qy Favourites aa Folders Folder Fol Home folder right click on the C3 Plastic Surgery folder and Clinical Haematology select Set as Home Folder EJ Alerts set as Home Folder l Ca BLT Global Favourites Please refer to User guide CLINO8 Generel Co mobidiies Ca Vascular Surgery for further details on favourite 9 ENT Mazilo Facial Surgery and Or
10. 4 zeok Pr IO ogoasz01s 3 3 How to make shortcuts with Autotext This is a CRS capacity with which you can make shortcuts that can automatically generate a full text by only typing a key word ZZZTEST LISTER 9678403 Opened by Cockerill Elisabeth Anne Ty p e t h e t ext yo u Wa n t to S a ve Task Edit View Patient Record Links Notifications Index Documents Help i 4 Patient List Message Centre Gy Home E Scheduling E i amp i Q EPR B i E Tear Off Pen Attach afl Exit a AdHoc amp PM Conversation v L Communicate a Access Management Office as an auto text zzzrEsT us x PE T Clinical Notes Print amp 11 minutes ago Patient Information Z r amp er EN KN amp m s g Select all the text you typed a n d Outpatient Summary al Last 500 Documents 47 out of 48 documents are accessible Document Count g Overview E Clinical Documents add Docume 2 9678 Si ka e t h e n rig ht C C k Chart Rewiew E Risk Assessments Allergies F Add Vital Signs E Messages Type Cardiology Md Author Cockerill ElisabethAnne g Anne aa Letters a Assessment and Progress Notes Date 14 04 2015 Bia 1248 H BST Status In Progress Histories amp ICU Transfer Summary Subject Select the option Save as Auto Requests Ga General Clinical Note E E H Activity List Handover Note H Problems and Diagnos Procedures and Diag
11. Cardiothoracic Surgery El Form Browser Clinical Notes Documentation F Add Pregnancy F add Appointments Cs ee Gos a Management to date iView Plan from post take consultant review P S regnancy Summary Current Issues O E BP HR Sat RR T ii Antibiotics 4 By Type Performed B Performed Date Action Status Proxy Clinical Staff By Status Perform Cockerill Elisabeth Anne 14 4pr 15 12 35 BST Completed C By Date Sian Cockerill Elisabeth Anne 14 4pr 15 12 35 BST Completed v Pini VERIFY Cockerill Elisabeth Anne 14 4pr 15 12 35 BST Completed By Encounter Modify Docurnent LCOSPROD 321686208034 14 are B a Ca ee ae ee ec eo SO Be ok SOCCER ar Page 5 Type in under Insert Addendum Here When you are finished select sign The document will now display the newly added text at the bottom of the page and state in red that the Document Contains Addenda ZZZTEST LISTER 9 03 Opened by Cockerill Elisabeth Anne zw B d x Task Edit View Patient Record Links Notifications Index Documents Help i a Patient List Message Centre Qt Home E Scheduling i amp Q EPR B E Tear Off ERS Attach afl Exit i AdHoc amp PM Conversation L Communicate 7 Access Management Office List gt Recent Name oa Clinical Notes ecelseeaxlBslelae S Patient Information Inp
12. N3 using an alternative browser will result in an error message advising the user to access again using an approved browser Support Any issues including password re sets with connecting to e CL Over N3 should be raised as per below e Support is provided by the CGI Service Desk o Email IT Servicedesk uclh nhs uk o Contact number 0203 447 9367 o Hours of support 24 7 e Ensure when logging the issue you state that you are accessing e CL from Barts e All incidents raised will be assigned a ticket number that will be used in all future correspondence with the user Any issues relating to other applications used on the Barts desktop should be raised as per below o Email TBC o Contact number TBC o Hours of support 24 7 Page 25 Appendix 2 Autotext to be created for Cardiology ward rounds WR Initial WR Clinical lead 0965 Summary of presenting complaint Chronic Issues Social History Results Bloods ECG ECHO Management to date Plan from post take consultant review Current Issues O E BP HR Sat RR T Impression Plan 1 EDD 2 Follow up 3 Weekend plan ii Antibiotics Abx Indication Agent Duration Stop Date Advice from microbiology WR Daily WR Clinical lead 0965 Current Issues Chronic Issues including past medical history amp social history Results Bloods ECG ECHO O E BP HR Sat RR T Impression Plan 1 EDD 2 Follow
13. Performed Date Proxy Clinical Staff Requested B Perform Cockerill Elisabeth Anne 14 Apr 15 12 35 BST Completed Sign Cockerill Elisabeth Anne 14 A4pr 15 12 35 BST Completed VERIFY Cockerill Elisabeth Anne 14 A4pr 15 12 35 BST Completed Sign Cockerill Elisabeth Anne 14 Apr 15 12 38 BST Completed Modify Cockerill Elisabeth Anne 14 Apr 15 12 38 BST Completed LCOSPROD 321686208034 14 April 2015 12 59 BST m ee 10 A 4 By U TERET mO sears Page 19 ST LISTER pened b ckerill Elisab nne a maj x Task Edit View Patient Record Links Notifications Index Documents Help i Patient List Message Centre a Home E Scheduling i ay i Q EPR i E Tear Off ne Attach H Exit a AdHoc amp PM Conversation L Communicate y Access Management Office E zzzrEsT us x ee teenz ome A How to modify pre existing entries a O A SS Print amp 0 minutes ago I Once within the patient s ZT acs a x Bls npatient Summary Outpatient Summary l wee ee ee ee ee eee ae accessible Document Count gt record see above steps a Poe z ET FEFA E Risk Assessments Final Report Ci ilere Faa ME Vital Signs Dr Wraggs clinic notes 1 8 Click on Clinica LT a bev m ran and ee E Letters h f h roceaures and agn a Assessment a
14. S seve ra d iffe re nt m et h od S to made Last 500 Documents 43 out of 44 documents are accessible Document Count Overview 29 Adu Nyarko George poen a OW fo r ease of searc h in g Chart Review Cockerill Elisabeth Anne Final Report Allergies Add ma Consultant TWO CSTestPROD Document Contains Addenda a Goldie Boyd a Th iS SC ree n S h ot d is p ays Problems and Disgnoss Gutteridge Charles Norman Procedures and Diagn 29 Kooner Paul pril 2015 12 17 BST Verified s ur Histories McDonnell Andrea EPE documents by performed by e B nani ci Activity List ia McGeary Caroline Louise 1 r Nash Jonathan Result title Cardiology Clinic Dr Wragg SO YOU can VIEW documents you LS a etre Performed by Cockerill Elisabeth Anne on 07 April 2015 15 10 BST Form Browser Ea Soni Rashmi Verified by Cockerill Elisabeth Anne on O7 April 2015 15 10 BST have created yourself You can i l Documentation also filter by Type by Status by isis Date and by Encounter n zl C By Type Performed B Performed Date Action Status Proxy Clinical Staff Requested Date Regu By Status Perform Cockerill Elisabeth Anne O7 4pr 15 15 10 BST Completed C By Date or 15 15 10 BST Completed G pr 15 15 10 BST Completed Pesiernied Ey pr 151217BST Completed By Encounter Mout Schell EEE BYAp 151217BST Completed LCO9PROD 321686208034 08 April 2015 12 22 BST x 12 22 m By a
15. TTA discharge summary and TTAs G2 speech clinical dictation refer to Dendrite Pats clinical audit Sectra PACS images see Appendix 5 UCLH CDR images e CareLogic e CL see Appendix 1 Circle cvi42 MRI and cardiac CT reporting Echo analysis software to be confirmed WinPath Pathology How to access Cerner Millennium Log into your PC using user name amp password provided from ICT department Insert Smartcard into card reader A pop up box will appear prompting you to enter your password Enter password and select enter Select the relevant access role starting with BARTS AND THE LONDON NHS TRUST Cerner millennium live can now be accessed via Start menu Page 3 Inpatient Documentation Clinicians Double click on the PowerChart icon y 3 1 Patient Lists On the patient list double click the name of the patient on whom you want to make a new entry This will open up the patients CRS record Patient List BS gt gt el mH SB Blane 2 Devonshire Ward General Medicine All Patients Devonshire Ward Fae ff TEST ANJKARA Bay 1 OF Female 45 years 9252811 10 0 Dap GALLAGHER Christopher Medical Oncology BOOMLA4 S oy Fad ff TEST ANJGARETH Bap 2 10 Male 75 pears 9252814 99Dap Dow Claire Geriatric Medicine BOOMLA 5 ZZA TEST ANJROBERT Bap 3 12 Male 48 years 9252857 61 Day Dow Claire General Medicine BOOMLA 5 ft 3 2 How to make new documentation entries on Cerner
16. The Barts Heart Centre Millennium User Guide Written by Dr Elpida Charalampaki July 2014 Developed in consultation with Cardiology Team Dr Andrew Wragg Dr Christopher Primus Dr Vikas Kapil Dr Tania Dexter Revised version 25 03 15 Page Table of Contents Tis COWS VIG W ee a E E E E E E E E N 3 2 How to access Cerner Millenniuim ccccccecccecceeeteeeceeeseeeseeceeceeeeeueeeeeeeeneeeanes 3 3 Inpatient Documentation Clinicians ccc ccccceccceeceseeeeeceeeseeeeeeteeeeeeeeeeteeeeaeenes 4 4 Inpatient Documentation Nurses cee cecc eee ecceeceeeeeeeeeceeeeeeseeeaeeeeeeueeeeeseeees 13 5 Outpatient Documentation Clinicians cece ccccceeceee eset eeeeeceeeteeeeeeseeeaeeteeens 15 6 Outpatient Documentation Nurses cccceceseceeeeceeeseeeeeeeeeeteeeeeeeeseeseeteeenes 223 T TMGUDIC SINOOUNG sosise esiti ENE A 244 8 AN X 1010 C gt 25 Appendix 1 e CareLogic e CL over N3 Barts User Guide e Appendix 2 Autotext for Cardiology Ward Rounds e Appendix 3 Autotext for Thoracic Ward Rounds e Appendix 4 Autotext for Cardiac Ward Rounds e Appendix 5 Barts Heart Centre Quick Reference Guide for viewing historic Heart Hospital Imaging Page 2 1 Overview Functionality will be primarily based around the use of Cerner Millennium which will be connected and integrated to the following systems o EPR clinical documentation e
17. al Staff __ Requested B C By Status Perform Cockerill Elisabeth Anne 14 Apr 15 12 35 BST Completed By Date Sign Cockerill Elisabeth Anne 14 Apr 15 12 35 BST Completed Clestomedee VERIFY Cockerill Elisabeth Anne 14 Apr 15 12 35 BST Completed By Encounter i 7 Click the right mouse button to adjust the search criteria LCOSPROD 321686208034 14 April 2015 12 36 BST a SU amp Glo ke mh Be Task Edit View Patient Record Links Notifications Index Documents Help 4 Patient List Message Centre a Home E Scheduling p amp Q EPR T Tear Off FEY Attach H Exit ai AdHoc a PM Conversation L Communicate M Access Management Office a 4 List gt Recent gt Nare Patient Information Inpatient Summary Outpatient Summary Last 500 Documents 47 out of 48 documents are accessible Document Count D Overview P Clinical Documents x Chart Review 5 Risk Assessments Document Contains Addenda 65 Vital Signs i For Ward Round E Messages WR Initial 65 Letters 64 Assessment and Progress Notes 5 ICU Transfer Summary General Clinical Note EJ Handover Note Chronic Issues Surgery 5 Perioperative Record E Emergency Department Documents Cardiology p Bloods o 14 Apr 15 11 41 BST Cockerill Elisabeth Anne DrW ECG EG 14 Apr 15 12 33 BST Cockerill Elisabeth Anne IPW f ECHO 65 Cardiothoracic Surgery Allergies Add Proble
18. al Surgery 9 Thoracic Procedures and Disorders folders E Seal Gosari as ee Patient s diagnoses and previous procedures will be entered into Millennium as SNOMED coded Diagnoses and Procedures and Investigations supported by Favourites folders 5 3 Requesting of diagnostic tests e g ECHO Refer to user guide CLINO5 for further details Once you have located the patients record Click on the Add button Patient Iimforrrmniswatior next to the Requests option wre rie Allergie Chart Peewee FProbkblierm n s amd Oia gr ProeceduresSsS and Diag Historie AE e guests A C tiit L iSt A e sults erwi enr F arm ArGe S er lirica M oote MmocurmleSnitationm FPredgdnamioyw o po ote e oi tS Enter the name or the start of the ZR NUTERE ii PE LLETEST RNJANGELA name of the request in the Find PAPAE RNJANGELA search box The user may search for any order Diagnosis Problem beng Addressed this Vit Find te A Type Ay in within the entire trust catalogue l dag Aad Covet il h 4 ti il J Falder Search wiin fa doy f 0 using either the Starts with or ee Se eee Contains options Note that the C Veru tndonb ETUC et ______ system requires a minimum of 3 characters when using the Contains option Next to each test there is a E icon Click this icon to find out Page 17 more about a test using the link displayed in the reference te
19. an access it ensure you sign during the WR Following days on Ward e Ward rounds are documented daily as a sequel of the initial entry e This can be done by going to documents as noted above and right clicking on the document titled IP WR WK1 Cardiology and selecting modify from the list of provided options e You will not be able to save the document now only sign it e Every Monday regardless of whether a patient was admitted on any other day apart from Monday you will need to generate a new weekly document e Title the entry WR WK 2 3 4 Cardiology accordingly depending on which week you are on the patient s in hospital stay 3 5 What are we documenting on each ward round entry What you would have documented in a normal paper ward round Given the experience the team has had with electronic documentation and an on going audit we have agreed on a minimum of information that needs to be included However complicated this might sound it does serve a purpose especially out of hours and in the event of a cardiac arrest In this context it is very difficult for the arrest team to be going through paper as well as electronic documentation To make this less time consuming we use shortcuts and in particular auto text 3 6 Auto texts we use For clarity and for continuation we use the auto texts in Appendix 2 3 and 4 that you need to save in your Smartcard before starting with Cardiology firm Please see above 3 3 How to
20. atient Summary Outpatient Summary al Last 500 Documents 47 out of 48 documents are accessible Document Count gt Overview Clinical Documents w Modif cument ZZZTEST LISTER 9678403 Chart Review S Risk Assessments z da Vital Signs __ E Messages Type Cardiology z FAuthor Cockerill Elisabeth Anne roblems and Diagnos AVL etters s Date 14 04 2015 BST Status Euh Verified Procedures and Diagn Assessment and Progress Notes al Histories E ICU Transfer Summary Subject JIP WR WK 1 Cardiology Requests SF Add General Clinical Note Associated Clinical Staff Modify Activity List Handover Note Patientlevel Document 7 Results Review oO Surgery F B Perioperative Record orm Browser Emergency Department Documents fio E Z z Clinical Notes Cardiology T ke ala Ey es BY Z 3 wll o Documentation F Add E 14 Apr 15 11 41 BST Cockerill Elisabeth Ar Pregnancy F Add E 14 Apr 15 12 33 BST Cockerill Elisabeth Ar Cardiothoracic Surgery Appointments View Pregnancy Summary Insert Addendum Here Perform Cockerill Elisabeth Anne 14 Apr 15 12 35 BST Completed v Sign Save Save amp Close Cancel 4 gt lii Antibiotics S 4 By Type Action Performed B Performed Date Action Status__ Comment Proxy Clinic
21. cedures and Diag Histories Requests Activit List Results Reviewer Form Browser Clinical Motes DCoacurmentation Pregnancy Mpa Appointments Diagnosis the higher window Problems and Diagnoses amp Print 2 0 minutes ac Mark all as Reviewed r Diagnosis Problem being Addressed this Visit Problems the lower window pia ee oe baa C pe ertmaion S E Ra Geno U0 2 Reopens CrealSat_ 3 Head injury Working Confirmed 14 07 2011 Non Specified ANJClinical Prac Access 02 op fan d d Venous thromboembolism risk assessment Admitting Confirmed 14 07 2011 Non Specified RNJClinical Prac Access 02 Click on type and search the diagnosis you want to add r Problems Add 4 Modiy Convert Display AN wj _ dal Annotated Display Name of Problem Onset Date Ran Last Updated Last Updated By Classification Life Cycle Status Life Cycle Asthma Asthma 14 07 2011 ANJClinical Prac Access 02 Active Lives alone Lives alone 14 07 2011 RNJClinical Prac Access 02 Active Hypertension Hypertension 14 07 2011 RNJClinical Prac Access 02 Active Click on Search by Name Search gastritis Set filter to contains returns more Search oy Code CO d e d terms Terminology JSNOMED CT ea Terminology Axis lt All terminology axes Se ect t h ea p p ro p ri ate S N O M E D EL View Synonym FE Concept Family EE MultiAxial a Cros
22. e N3 connected user enters the URL for e CareLogic into the Barts desktop through Internet Explorer 8 URL https nww ecarelogic uclh nhs uk 2 Users must have an e CL account provided by UCLH and these credentials should be used to access e CL over N3 3 The user must enable pop up blockers in order to launch the site If unsure how to do this then contact Barts support desk 4 The user must select yes when presented with the following pop up message The webpage you are viewing is trying to close this tab Do you want to close this tab 5 The session will remain open as long as the browser window is open When closing the browser window the session will expire and the user will need to login to access again see step 1 Compatibility Settings The user must ensure the following compatibility settings are enabled e Check if Compatibility View is enabled under tools gt compatibility view settings e The above settings only need to be applied once Functionality Available on e CL over N3 There are some areas which will be unavailable to users accessing e CL over N3 Areas unavailable e PACS Web access e Op Notes drawings e Document scanning e Ops Centre reports e 18 week reports e Certain Links where these point to URLs internal to UCLH Desktop Requirements e e CL is at present is only warranted for desktop access and not laptops or tablets e Windows 7 e Internet Explorer 8 Attempts to access e CL over
23. e Y N AT Routine once a dey Blood nde cad anemia 12345 Page 18 5 4 Notes from the consultation will be entered into Millennium as a Clinical Note Click on Clinical notes on the left hand side of screen to make new entry Once clinical notes have been selected Left click on this icon This will bring up the new document box First select type of note For ward round reviews select Cardiology or Cardiothoracic surgery note The fastest way of doing so is by just typing C Then put the title on the Subject space e g Dr Wragg Cardiology Outpatient You are now ready to document your entry When you are finished select sign Note If you select save you will be the only one who can access the entry This might be useful if you want to temporarily save your entry so that you can amend it later Menu Inpatient Summary Outpatient Summary Patient Information overview Chart Review Allergies Problems and Diagnoses Procedures and Diagnoses Histories Requests activity List Results Review Form Browser Clinical Motes Documentation Pregnancy Appointments Add Add Pregnancy Summary Patient Information Inpatient Summary Outpatient Summary Overview Chart Rewiew Allergies Problems and Diagnos Procedures and Diagn Histories Requests Activity List Results Review Form Browser Doc
24. fied RNJClinical Prac Access 02 oi fan d d 8 Venous thromboembolism risk assessment Admitting Confirmed 14 07 2011 Non Specified RNJClinical Prac Access 02 Diagnosis the higher window Click on type and search the diagnosis you want to add m Problems Add 4 Modify Convert Display An J a Annotated Display Name of Problem Onset Date Ran Last Updated Last Updated By Life Cycle Status Life Cycle a Asthma Asthma 1950 14 07 2011 RNJClinical Prac Access 02 Active 14 07 201 Lives alone Lives alone 2005 14 07 2011 RNJClinical Prac Access 02 Active 14 07 201 Hypertension Hypertension 2008 14 07 2011 RNJClinical Prac Access 02 Active Click on Search by Name Search gastritis Contains x Within Terminology x Search by Code more co d e d terms Terminology SN OMED CT E Terminology Axis al terminology axes gt jem Se e ct t h ea p p ro p ri ate S N O M E D E E Concept Family Ee Multi Axial Cross Mapping Temi ode Terminology Terminology Axis term Acute and chronic gastritis 177628901 4 SNOMED CT Finding Acute erosive gastritis 31470019 SNOMED CT Finding Acute erosive gastritis 1223131010 SNOMED CT Finding To add the SNOM ED term to your Acute erosive gastritis 478551013 SNOMED CT Finding Acute gastritis 42686017 SNOMED CT Finding H i Acute haemorrhagic gastritis 47855301
25. formed B Performed Date Proxy Clinical Staff Request Commen By Status C By Date Performed By C By Encounter aa LCO9PROD 321686208034 30 March 2015 15 54 BST ro sm n s eas 15 54 A gs w PS ie g s k 4EsBOeows PS 30 03 2015 Selenite dult ZZZTEST LISTER E E in S l HE CC mma 30 03 2015 l 1602 BST By Cockerill Eli ED Adult Vital Sig Adult Vital Signs Respiratory Rate bpm br min Sp02 In Air gt Oxygen Concentration Sp02 On Oxygen 2 Oral Tympanic Axillary Rectal Skin Temperature Degrees C DegC DegC Degl Degl Degl Heart Rate bpm bpm Blood Pressure mmHg i mmHo MAP Conscious Level Alert Confused Verbal Pain Unresponsive NEWS Total CRT Blood Glucose mmol 1 mmol Weight Estimated kg ko Height Estimated cm cem BMI Estimated eight Measured kg 3 Height Measured cm BMI Measured 22 49 kg m2 Actual L Min L min Best L Min L min Predicted L Min L min Percentage Percentage Pain Score Os zi No Pain Mild Pain Moderate Pain Severe Pain i Ee 4 6 7 10 4 i e pl CA AT 7 ij as w z 7 m m ad j s n Peer 5 SU EEG JAS separo Page 23 7 Troubleshooting 7 1 CRS downtime Ensure you have undertaken your CRS training and you have a valid Smartcard If both you and your colleagues are unable to log into CRS it is very likely this
26. isa CRS downtime issue In this case ward round can be typed on a word document and then copied and pasted to CRS when the system is once again live There are plans to have a back up system in the near future where past entries can be reviewed but not modified Blood results can be accessed via Winpath and images via Barts Health PACS viewer Log On to Windows 7 2 Winpath access racer i fg en Go to start menu Copi 1905 2053 amare Select option _WardEnq Type in your personal logging details in the first window titled LogOn to Windows wit Down _Options lt lt Type in the following details in the second window titled System Logon Login hourihm Password ft Change ar Password Price12 7 3 Logging issues with ICT helpdesk e ICTservicedesk bartshealth nhs uk e 47680 or 020 7377 7680 e Or for urgent ICT problems please call the dedicated Barts Heart Centre ICT hot phone live now 07984368192 If you choose to log an issue with ICT via email remember it is helpful to copy and paste a print screen of the error message you get on your screen to the email you send to ICT Page 24 Appendix 1 e CareLogic Over N3 eportenoe tha C AA Barts User Guide Access to e CareLogic e CL is now available to users with valid login credentials This is a user guide on how to access e CL over the N3 network and also includes details for support Gaining Access to e CL over N3 1 Th
27. l 2015 15 29 BST A s 15 29 wa BM p c Br 8 1 i a Pr 7 2015 3 4 Basic Ward Round documentation principles on CRS Day 1 on Ward Make a new entry on CRS as d es C ri b e d a b ove vi a clin ical Sen ane mee ae Documents Help 4 Patient List Message Centre t Home E Scheduling a g A Q EPR E Tear off E Attach Hf Exit a AdHoc a PM Conversation L Communicate z Access Management Office notes not documentation Title TT it IP WR WK1 Cardiology Clinical Notes Patient Information a Zs Sp arx E KN amp m g Inpatient Summary To n se rt t h e n a mMm e of t h e Outpatient Summary Last 500 Documents 47 out of 48 documents are accessible Document Count Overview Clinical Documents e e C e C k Chart Rewiew E Risk Assessments onsultant in your entry click on c Bene E Messages Type Cardiology z Author Cockerill Elisabeth Anne oh 5 Letters 65 Assessment and Progress Notes Date 14 04 2015 Bia z est Status In Progress ICU Transfer Summary Subject IP WR WK1 Cardiology E General Clinical Note Handover Note Associated Clinical Staff Modify Surgery PatientLevel Document I 6 Perioperative Record 65 Emergency Department Docum a Cardiology Arial Jh A Ala selel BIUS E slt a 6 amp 5 Cardiothoracic Surgery a t Add Document ZZZTES modify This is
28. make shortcuts with Autotext Page 9 3 Ward Round Entry e WR Clinical lead bleep e Summary of presenting complaint include at least the day of admission and presenting complaint e g 48 year old lady admitted on the 09 12 with SOB e Chronic Issues refers to PMH amp SH Given that we found that on many occasions we omitted the social history on at least the Initial WR entry you are also prompted to provide a SH below chronic issues e Results refer to relevant presenting blood results blood Gases ECG other investigation results You are expected to have at least documented significantly abnormal blood results Troponin if appropriate ECG finding and ECHO e Management to date refers to the treatment the patient has received for example ACS protocol diuretics inhalers depending on the main issue e Plan from post take ward round refers to the plan made by the Cardiology Consultant who first reviewed the patient post triage This is again because post take happens on the Acute Medical Ward where documentation is on paper e Current issues refer to the problems that are keeping the patient in the hospital or issues that have been recognised during this admission This means that although a patient might not be kept in the hospital because of hypokalaemia it is still an issue that needs to me addressed e O E On examination refers to current observations amp current examination It is absolutely crucial that you make sure a n
29. ment will now display the newly added text and state in red that the Document Contains Addenda Using Filters to View documents Documents can be filtered by several different methods to allow for ease of searching This screen shot displays documents by performed by so you can view documents you have created yourself You can also filter by Type by Status by Date and by Encounter amp ZZ7TEST LISTER 3 Opened by Cockerill Elisabeth Anne a j A i x Task Edit View Patient Record Links Notifications Index Documents Help A Patient List Message Centre i Home 3 Scheduling i amp zB Q EPR B SS Tear Off RE Attach H exit aaj AdHoc amp PM Conversation L Communicate X Access Management Office zzzrest us x is tec so Clinical Notes J Print 20 minutes ago ace Sze x BX Glace g Patient Information Inpatient Summary Outpatient Summary Last 500 Documents 44 out of 45 documents are accessible Document Count gt Overview Clinical Documents A Chart Review Final Report Allergies Add Document Contains Addenda Problems and Dagnis Dr Wraggs Clinic notes Procedures and Diagn Addendum by Cockerill Elisabeth Anne on 08 April 2015 13 07 BST Verified Histories Additional information added Requests add Activity List Results Review Result title Dr Wragg Outpatient Notes Performed by Cockerill Elisabeth Anne on 08 April 2
30. millennium How to Modify Amend and how to search for documents using Filters Inpatient Summary Click on Clinical notes on the Outpatient Summary Patient Information left hand side of screen to make overview Chart Review new entry Allergies Problems and Diagnoses Procedures and Diagnoses Histories Requests Activity List Results Review Form Browser Clinical Motes Documentation add Pregnancy Appointments Pregnancy Summary Newborn Summary Once clinical notes have been selected Left click on this icon Page 4 4 ZZZTEST LISTER 9678403 Opened by Cockerill Elisabeth Anne This will bring up the new document box Task Edit Wiew Patient Record Links Notifications Index Documents Help 4 Patient List Message Centre Gh Home E Scheduling Eg i amp Q EPR i Tear Off nen Attach Ml Exit aj AdHoc amp PM Conversation L Communicate z Access Management Office 4a List gt Q Recent 7 Name eo SH Print 2 45 minutes ago First select type of note For Patient Information ward round reviews select Den O O eceleeea x lBs Slacs Outpatient Summary Last 500 Documents 46 out of 47 documents are accessible Document Count gt i i i oj x Cardiology or Cardiothoracic Overview i Chart Review surgery note The fastest way aue op Fa i Type Cardiothoracic Surgery x Author Cockerill Elisabeth Anne oh Anaes
31. ms and Diagnos WR Clinical lead 0965 Procedures and Diagn Histories Summary of presenting complaint Requests Activity List Results Review Form Browser Clinical Notes Documentation Add F Add Pregnancy Appointments Management to date View Pregnancy Summary Plan from post take consultant review Current Issues By Type Action Performed B Performed Date Action Status Comment Proxy Clinical Staff Requested B By Status Perform Cockerill Elisabeth Anne 14 Apr 15 12 35 BST Completed By Date Sign Cockerill Elisabeth Anne 14 Apr 15 12 35 BST Completed DFi VERIFY Cockerill Elisabeth Anne 14 4pr 15 12 35 BST Completed Sign Cockerill Elisabeth Anne 14 Apr 15 12 38 BST Completed By Encounter Modify Cockerill Elisabeth Anne 14 Apr 1512 38B5T Completed 4 gt LCOSPROD 321686208034 14 April 2015 12 38 BST p r i 12 38 ae SO Bee Poe 14 04 2015 Page 6 4 ZZZTEST LISTER 967 Jpened by Cockerill Elisabeth Anne Task Edit Wiew Patient Record Links Notifications Index Documents Help i a Patient List Message Centre t Home E Scheduling i Ay Q EPR B E Tear Off rey Attach Mp Exit aij AdHoc amp PM Conversation L Communicate Z Access Management Office Using Filters to View aT ETT documents Documents can be filtered by Pie 5 ites 290 Patient Information 1 Inpatient
32. n amp Surgery PatientLevel Document 7 Results Review 5 Perioperative Record text Yo 7 wW i b e a S ke d to een aaa E Emergency Department Documents e A EE Arial jo a selel Bulzis alot o provide an abbreviation TLL r a Pregnancy F Add a i Appointments R Clinical lead 0965 View Hide Toolbar Summary of presenting complaint P S regnancy Summary Import Chronic Issues Export Insert Auto Text Sign Save Save amp Close Cancel v 4 gt By Type Action Performed B Performed Date Proxy Clinical Staff Requested B C By Status Perform Cockerill Elisabeth Anne 14 Apr 15 12 35 BST Completed C By Date Sign Cockerill Elisabeth Anne 14 Apr 15 12 35 BST Completed C Performed B VERIFY Cockerill Elisabeth Anne 14 Apr 15 12 35 BST Completed y Sign Cockerill Elisabeth Anne 14 Apr 15 12 38 BST Completed By Encounter Modify Cockerill Elisabeth Anne 14 Apr 15 12 38 BST Completed 4 LCO9PROD 321686209034 14 April 2015 12 49 BST P 12 49 Bw n Br t 1 cg OM Bea me a025 Page 7 a a gt ZZZTEST LISTER 9678403 Opened by Cockerill Elisabeth Anne Ty p e t h e Ab b revi at l O n a n d Task Edit View Patient Record Links Notifications Index Documents Help i amp Patient List Message Centre G Home Scheduling iG Q EPR B i E Tear Off E Attach Hf Exit AdHoc amp PM Con
33. nd H fResult title Dr Wragg Outpatient clinic notes notes O n t e e t a n d Histories ICU Transfer Sum Performed by Cockerill Elisabeth Anne on 08 April 2015 13 09 BST Requests General Clinical N verified by Cockerill Elisabeth Anne on 08 April 2015 13 09 BST side of screen select the Acti a eari 7 Results Review a Surgery oo Perioperative Rec document you wish to Bia Emergency Dep y i Fe Documentation F Add modify and left click on Pregraney Fa Appointments h d if View t e M O l y l CO n Pregnancy Summary Be Action PerformedBy PerformedDDate Action Status _ Comment _ Proxy Clinical Staff RequestedBy RequestedDate _ Request Comment By Status Perform Cockerill Elisabeth Anne 08 Apr 15 13 09 BST Completed C By Date Sign Cockerill Elisabeth Anne 08 Apr 15 13 09 BST Completed C Petformed By VERIFY Cockerill Elisabeth Anne 08 Apr 15 13 09 BST Completed By Encounter i i Modify Document LCOSPROD 321686208034 08 April 2015 13 09 BST g l 5 m a O 08 04 2015 Task Edit View Patient Record Links Notifications Index Documents Help a Patient List Message Centre t Home 3 Scheduling i Ge Q EPR B E Tear Off 2 Attach fl Exit a AdHoc amp PM Conversation L Communicate z Access Management Office 4 List gt C Recent Name Type in under Insert Addendum Here
34. ote is made of at least patient s vitals e Impression can be as per current issues or at least a comment on whether team thinks patient is doing better or worse e Plan EDD Estimated discharge date make sure you prompt your senior to provide you with such a date This will turn out to be very helpful for many things including the morning MDT as well as prioritising the discharge letters you have to write Follow up plan needs to be documented if patient s discharge date is approaching If it is Friday a weekend handover will need to be made for the patient This will help you when populating the weekend handover application You will know beforehand which patient will need to be reviewed by whom FY1 Medical SpR Cardiology SpR If patient is unwell make sure there has been some consideration of the escalation plan should they deteriorate out of hours Daily ward round is documented on the same principles However the feeling is that there is no need to duplicate information such as the post take plan as long as it has been Page 10 documented electronically On going issues should be documented daily as they ensure there is on going consideration of both acute and chronic problems as well as for discharge planning 3 8 SNOMED coding hi e rn Within the patients record Select a Problems and Diagnosis from the Ove niew Allergie s Menu options displayed on the Chart Review k Problems and Diagn left of the window Pro
35. pril 2015 12 57 BST 1257 ERBA t g a 7 f eEeBGegyvs IO aws Page 14 5 Outpatient Documentation Clinicians 5 1 Scheduling Lists will be used to navigate clinic lists Within Powerchart Click on Scheduling icon on Tool bar Or Click View in Task bar and select Scheduling To View a Clinic List for Lead Clinician In the Resource field Click on the binoculars to select the consultant Enter the required Clinic day in the Date field The clinic for the chosen clinician will display t Task Edit a PowerChart Organiser for SixHundredSix Trainer View Patient Record Links Notifications Inbox Help Message Centre fa Home cs Patient List 8 Scheduling 1 i iy Consy t PowerChart Organiser for SixtHundredSix Trainer Task Edt Wew Patient Record Lnks Hotfcations Shedde Heb Message Certe Home 3 Pattit shedding 6 4 Corsu Resulet E Qer L T Te of Taah Me Madho G pm cameron Sf Communicate G Resat Copy Bypested pects Access Management fe Arete Nane A grn rinsa EEE Sr rC C i NN CNWSUNSN Time Name Duwa Deso a ity D 5 2 Reason for consultation to be entered into Millennium as a SNOMED coded Problem Ensure you have selected the correct patient on the patient banner bar ae Add Click on Problem Problems and Diagnoses Mark all as Reviewed r Diagnosis Problem being Addressed this Visit Convert Display Jaw x fas Clinical Dx Dx Type Confi
36. rch 2015 15 54 BST a F gt x P a E O xs wi PS S g k a da Io sell Bs iskin Adult ZZZTEST LISTER mo z Click in Weight vad ELE seme 4 M easure d an d recor d eee 20 03 2015 Hf ff1602 ET BST TEET ED Adult Vital Sig actual weight Adult Vital Signs C i C k i n H e ig h t Respiratory Rate bpm b M easu red an d reco rd Sp02 In Air 2 Oxygen Concentration Sp02 On Oxygen a ct u a Oral Tympanic Axillary Rectal Skin i Temperature Degrees C DeC Deac Deac Deac Dest E This automatically Heart Rate bpm bm creates and records th BMI Blood Pressure o mhg i o mig MAP v X e z z Alert Confused Verbal Pain Unresponsive Conscious Level NEWS Total m Click on the Tick to sign CRT Blood Glucose mmol 1 mmol Weight Estimated kg a Height Estimated cm cM BMI Estimated eight Measured kg 2 Height Measured cm cm BMI Measured 22 49 kg m2 Actual L Min L min Best L Min L min Predicted L Min L min Percentage 2 Percentage Pain Score O9 z No Pain Mild Pain Moderate Pain Severe Pain 0 1 3 4 6 7 10 a7 mo Su oO hol E e naow e ran Page 13 4 2 Entering a Nursing Care Evaluation Inpatient Summary Outpatient Summary Click on Clinical notes on the left hand side of screen to make new entry Patient Informa
37. rmation Das ge Add E Modify Head injury g Print amp 0 minutes ac Cinical Service _ Ra Classi La 24 Responsible Cinical stat _ 3 Working Confirmed 14 07 2011 Non Specified RNJClinical Prac Access 02 Venous thromboembolism risk assessment Admitting Confirmed j1 4 07 2011 Non Specified RNJClinical Prac Access 02 m Problems de Ad 4 Modify Convert Display aooo E BE Annotated Display Name of Problem Onset Date Ran Last Updated Last Updated By Life Cycle Status Life Cycle Asthma Asthma 1950 tive 14 07 2011 RNJClinical Prac Access 02 Aci 2005 14 07 2011 RNJClinical Prac Access 02 ives alone e u 2008 14 07 2011 RNJClinical Prac Access 02 14 07 201 Page 15 wien Within the patients record Select Patient Information lve Pri enn Problems and Diagnosis from the Allergies hart Reviews Problems and Diaqgn Menu options displayed on the r ae Histories left of the window didi Was Activity List Results Reviews Form Browser Clinical Motes DCoacurmentation FPreqnancy Mpa Appointments Problems and Diagnoses amp Print amp 0 minutes ac Mark all as Reviewed m Diagnosis Problem being Addressed this Visit Problems the lower window fl ah tee oe a l e a e T a Seca Ra Cen Be Remeber Sa S Confirmed 14 07 2011 Non Speci
38. s Mapping term Acute and chronic gastritis 1776289014 SNOMED CT Finding Acute erosive gastritis 31 470019 SNOMED CT Finding Acute erosive gastritis 1223131010 SNOMED CT Finding To add the SNOMED term to your Acute erosive gastritis 478551013 SNOMED CT Finding Acute gastritis 42686017 SNOMED CT Finding F avou rit es f O d erc i C k A d d t O Acute haemorrhagic gastritis 478553011 SNOMED CT Finding Acute haemorrhagic gastritis 481682013 SNOMED CT Finding Acute neutrophilic gastritis 35327501 4 SNOMED CT Finding Favourites Acute on chronic gastritis 1785555010 SNOMED CT Finding AG Atrophic gastritis 506116018 SNOMED CT Finding C i c k O K Alcoholic gastritis 4525015 SNOMED CT Finding j Alkaline reflux gastritis 502298012 SNOMED CT Finding Note that this is where you will also need to electronically record VTE assessment if not already done Make sure SNOMED coding is populated with all the diagnosis for each patient including Page 11 important information for patient s that are considered high risk For example if patient is homeless or an IVDU or colonised by bacteria MRSA positive has a permanent catheter and so on and so forth Page 12 4 Inpatient Documentation Nurses 4 1 Entering Height and Weight 4 gt ZZZTEST LISTER 9678403 Opened by Cockerill Elisabeth Anne T
39. the box aa Histories underneath the Subject box Regu Activity List right next to associated clinical 55 staff This should load another Documentation Add table Type the name on the Sein search box and click on the binoculars on the right click ok CO CS ee Gs eee God aa en a e aa e ss Go aa ea a a Pregnancy Summary vr 4 b Action Performed B Performed Date Action Status Comment Proxy Clinical Staff Reg gt l Sign Save Save amp Close Cancel v 4 gt By Type Performed B Performed Date Proxy Clinical Staff__ Requested B By Status Perform Cockerill Elisabeth Anne 14 Apr 15 12 35 BST Completed C By Date Sign Cockerill Elisabeth Anne 14 Apr 15 12 35 BST Completed PE eni VERIFY Cockerill Elisabeth Anne 14 Apr 15 12 35 BST Completed Sign Cockerill Elisabeth Anne 14 Apr 15 12 38 BST Completed By Encounter Modify Cockerill Elisabeth Anne 14 Apr 15 12 38 BST Completed t 4 LCO9PROD 321686209034 14 April 2015 12 53 BST 12 53 14 04 2015 ne ee Om Moe me 8 i Page 8 e Now you are ready to document the WR on the main table e If you have time prior to WR it is sensible that you prepare the summary and save it Unfortunately this can only be done on the 1 weekly entry As practical as this is note that when saving an entry it can only be viewed through your Smartcard No one else c
40. thetic Assessment Date E r Cardiothoracic Surgery Subject CDU Discharge Summary Clinical Clerking Problems and Diagnos Procedures and Diagn of doing so is by just typing C es 43 BST 43 BST Requests F Add Associate Dietetic Assessment rarer General Clinical Note Activity List EE Patient Handover Note es Results Review irs Form Browser Then put the title on the Subject space e g IP WR WK 1 u Cardiology Ifo AIS elel Buls E Sloe ol a Fl m Appointments iView Pregnancy Summary You are now ready to sl document your entry icin Poesy _ Peomed0ae Aan Sut Comet Png Grea Renstediy Rea 4 When you are finished select 4 ft T 2 By Type Action Performed B Performed Date Action Status _ Comment Proxy Clinical Staff _ Requested B S Ig n C By Status Perform Cockerill Elisabeth Anne 14 Apr 15 11 43 BST Completed C By Date Sign Cockerill Elisabeth Anne 14 Apr 15 11 43 BST Completed eey VERIFY Cockerill Elisabeth Anne 14 Apr 15 11 43 BST Completed By Encounter Note If you select save you will wi be the only one who Can access Click the right mouse button to adjust the search criteria fF ___ LLCO ROD 321686208034 14 April 2015 12 29 BST a OFT the entry This might be useful See ew oe of SEM OORE ENDO uuas if you want to temporarily save
41. tion overview Chart Review Allergies Problems and Diagnoses Histories Requests Activity List Results Review Form Growser Clinical Motes Documentation Pregnancy Appointments Pregnancy Summary Mewborn Summary Once clinical notes have been selected Left click on this icon This will bring up the new ZZZTEST LISTER 9678403 Opened by Cockerill Elisabeth Anne document box First select type of note For Menu Clinical Notes Procedures and Diagnoses add SS add Task Edit View Patient Record Links Notifications Index Documents Help A Patient List Message Centre Home E Scheduling e QER T Tear Off E Attach Mp Exit Sj AdHoc amp PM Conversation L Communicate j Access Management Office 4a List gt C Recent 7 Name SH Print 2 18 minutes ago Nursing Care Evaluation notes Patient Information e tplbE a xlaxeTt g Inpatient Summary select Cardiology or Oupetsumey E Overview Clinical Documents Cardiothoracic surgery note Ceen ED RakAsesmen Allergies P add H Vital Signs The fastest way of doing so is Paben ard Dagon Ja venas R i Procedures and Diagn by just typing C Hii Requests P Add Activity List Results Review E ICU Transfer Summary E General Clinical Note E Handover Note 5 Surgery E Perioperative Record H E Form Browser Documentation F Add Pregnancy F Add Appointments E Cardiolog
42. umentation Pregnancy Appointments View Pregnancy Summary Mewborn Summary 4 ZZZTEST LISTER 9678403 Opened by Cockerill Elisabeth Anne Task Edit View Patient Record Links 4 Patient List Message Centre Qf Home ES Scheduling iu i ag i Q EPR iB E Tear Off te Attach H Exit ai AdHoc amp PM Conversation L Communicate z Access Management Office SF Add Add Clinical Notes F Add Add Clinical Notes Notifications Index Documents Help List gt gt Recent z Name B 6p pE ax BAIST S P Clinical Documents 4 29 Risk Assessments H E Vital Signs H E Messages Letters H E Assessment and Progress Notes H E ICU Transfer Summary H E General Clinical Note Handover Note 6 Surgery Perioperative Record E Emergency Department Docum Cardiology H E Cardiothoracic Surgery By Type C By Status C By Date Performed By By Encounter Last 500 Documents 47 out of 48 documents are accessible Document Count 4 Add Document ZZZTEST LISTER 9678403 Type Cardio Date 14 04 2015 Hfz 1253 i BST Subject Dr Wragg Cardiology Outpatient Associated Clinical Staff Modify PatientLevel Document I h amp aal elel BIUlZs E Sign Save Save amp Close Cancel X 4 gt Performed B
43. unds Medications review VTE prophylaxis Aspirin Ranitidine Diuretic ACEi Betablocker Statin Analgesia Antibiotics Drug Indication Day Culture results Plan ECG Pacing Wires Antibiotics Bloods Discharge planning When TTAs Others changes and plans Page 28 Appendix 5 Barts Heart Centre Quick Reference Guide Viewing Historic Heart Hospital Imaging 1 Log on to Bart Health PACS the link can be found on all PC s Start menus Barts Health PACS Viewer using your Barts Health Trust computer login credentials Riogon SECTRA IDS7 Enter username and password to log on Username username Password Options gt gt Exit i 2 Click on the E amp H icon on the top tool bar to display the search area 3 To search enter the patient s name format Surname Forename and Date of Birth Alternatively changing the search criteria to Patient ID and searching with the patient s historic Heart hospital number prefixed with HH i e HH0012345 Search for examinations Iw Patient name Begins with a Date of birth DOB is v 01 05 2015 Advanced Search T Page 29
44. versation A Communicate Access Management Office Description of the autotext and PE re Nore then press save Paiontmtormaton ____s 26 e a xl Kem g From now on whenever you type the Abbreviation you will sissiessinns Overview be provided with the option of 2 Allergies SP Add Problems and Diaiis ____ Abbreviation Desciptin hastUpd ted System ge n e rat l n g t h e a uto text Procedures and Diag i a AEA TEARRE GMT Hames freetext autotext 02 Mar 2015 13 42 GMT WE Initial 02 Mar 2015 13 57 GMT Requests WR initial Activity List Results Review Form Browser A bE ab o Documentation F Add Abbreviation WR Pregnancy SP Add Appointments iview Abbreviation replaced by Description fWR initial Pregnancy Summary Details Type MWA InitialfWF Clinical lead 09650Summary of presenting complaintIIChronic l Formatted Text i Clinical Staff Reg gt I Save Discard e man ave Save amp Close Cancel Close 7 F 4 By Type Performed B Performed Date Action Status Comment Proxy Clinical Staff eqiedted Date C By Status Perform Cockerill Elisabeth Anne O7 Apr 15 15 10 BST Completed C ByDate Sign Cockerill Elisabeth Anne O7 Apr 15 15 10 BST Completed VERIFY Cockerill Elisabeth Anne O7 Apr 15 15 10 BST Completed C Performed By C By Encounter i LCO9PROD 321686208034 07 Apri
45. xt window that appears This is used for decision support Click on the Test s to be ordered The order will turn blue and be bold It is possible to select multiple orders together by clicking on them Each item to be ordered will be blue and be bold Click the Done button to proceed once all the requests have been selected Complete the Order Details ensuring the mandatory yellow fields are populated Once the request order entry fields have been completed there should be O missing required details shown in the bottom left hand corner click Sign The order status will be Processing on the Order Profile Click on the button showing the number of minutes since you last refreshed the screen This will refresh the screen The order status of the request will be updated from Processing to Ordered 222TEST RNJANGELA Add Order Diagnosis Problem being Addressed this Vist Find fii Contains Type amp inpatient Add Convert Display aN 7 al A g al Folder General Haemato Search within Pathology Atl 4 Cinical Dx 0 Blood Film Microscopy Venous thromboembolism ris 1132351 000000118 Bone Marrow Examination Erythrocyte Sedimentation Rate Erythropoetin Serum Infectious Mononucleosis Test Glandular Fever Screening IMST Paul Bunnell Iron Stain Neutrophil Alkaline Phosphatase Reticulocyte Count Viscosity Plasma Full Blood Count Malarial Parasite Screening
46. y 5 Cardiothoracic Surgery Then put the title on the Subject space e g Ward 4a Nurse Care Evaluation View Pregnancy Summary You are now ready to document your entry When you are finished select By Type C By Status sign ae C Performed By By Encounter Note If you select save you will be the only one who can access H E Assessment and Progress Notes E Emergency Department Docum Last 500 Documents 47 out of 48 documents are accessible Document Count 4 Add Document ZZZTEST LISTER 9678403 Type Cardiology Author Cockeril Elisabeth Anne rs Date yos Eele jest se Subject Ward 4a Nurse Care Evaluation Associated Clinical Staff Modify Patiert Level Document M Avil Aho z 9 aa selel Blus E fi Performed By Perfoimed Date Proxy Clinical Staff Reg 4 D ve Save amp Close Cancel v 4 Action _ Performed B Performed Date Proxy Clinical Staff Requested B Perform Cockerill Elisabeth Anne Sign Cockerill Elisabeth Anne 14 Apr 1512 35BST Completed VERIFY Cockerill ElisabethAnne 14 Apr 151235B5T Completed Sign Cockerill Elisabeth Anne 14 Apr 1512 38BST Completed Modify Cockerill Elisabeth Anne 14 Ap 1512 38B5T Completed 14 Apr 151235B5T Completed x the entry This might be useful if you want to temporarily save your entry so that you can amend it later LCOIPROD 321686208034 14 A
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