PCD TRAINING MANUAL
What is PCD??
“Patient Care Documentation”
Computerized nursing documentation
Developed by Siemen’s Company
Used on all hospital units except for the
ED, Labor & Delivery, Post partum,
NICU, and PICU.
Limited use in the Adult ICU - use the
admission history section only.
System Sign-on
The User ID & password
is your legal signature.
Contact the Help Desk
(4-2501) if you want to
change your password.
Never allow anyone else
to use your password.
Always log off when the
transaction is complete.
A record is kept of all
transactions.
System Sign-on
User ID and
Password will be
issued to you by
your faculty.
All student IDs will
begin with NST.
Use only while you
are at S&W as a
student.
Security
Students who are also employees of
Scott & White
If you are a student and an employee, you will
have a User ID and password for each role.
While you are at Scott & White as a student,
use the User ID that begins with NST.
Do not use this ID when you are at Scott & White
as an employee.
While you are at Scott & White as an employee,
use the User ID that was provided through
Human Resources. Do not use this ID when you
are at Scott & White as a student.
Accessing information using the incorrect
User ID, is grounds for termination of
employment, and clinical privileges
Nurse Station Census
Net Access navigator bar.
Can be used to locate patients
by name or MRN inquiry.
The unit census defaults to where the
user signs on.
Nurse Station Census
View census of another unit by selecting Unit Census
from the Navigator Bar and choosing the unit
Patients are listed in Room/Bed order,
Name highlighted in blue and underlined
Click once on the patient name to select patient.
More Navigator Facts
Once a patient is selected
different functions are available.
The patient’s name and the user ID display at the top of the screen
Items preceded by a sphere display multiple options when item is selected
Vital Signs
Charting Vital Signs
Defaults to current time,
may change date and time.
Can NOT chart in the future
Use spin buttons
or type In the values
Move from field to field using mouse or tab key
Charting Vital Signs
To add more
vital signs,
Click here.
Click update complete to chart
Click on cancel to
exit pathway without
entering data.
Revise Vital Signs
Indicates the person
Entering the data
Vital signs are grouped in reverse chronological order.
Revise Vital Signs
From the vital display,
select vs to be revised
Then click on revise.
Revise/Delete Vital Signs
Choose radio button:
1.
Revise result to change incorrect data on correct patient.
2.
Mark as error to delete data entered on wrong patient.
Once chosen, fields are enabled to allow revision. Make changes and
Click OK
When using Mark as Error,
A reason must be entered.
Using skip button allows user
To leave screen without making
Changes.
Display Vital Signs
Revised VS will display this way
Vital Signs mark as an error display this way
This displays the last 5 sets of VS. To see all
since admission, click all.
Intake and Output
I&O
Entering I&O
Select box in front of source to delete a
source that is no longer needed. The box
will be grayed out if data has been
entered in the last 24 hours
Exclude sources are not included in
the I/O totals.
An “X” will display in the Excld
column. IE Stool Count
Enter amount
of intake or
output in mls
Click OK to store data
Select Add Comments to
Enter additional data about I&0
Enter the date/
time I & O
collected
Comments
A comment field is provided
For each I&O source
Click OK when completed
Intake & Output Sources
Select intake or output to add
sources
Click Add when
desired sources have
been selected
Revise I&O
Only licensed staff can revise
Shows the date/time interval
for the displayed data.
Select the item(s) to be revised
Click revise
T indicates comment
Revise I&O
Choose radio button:
1.
Revise result to change incorrect data on correct patient.
2.
Mark as error to delete data entered on wrong patient.
Once chosen, fields are enabled to allow revision. Make changes and
Click OK
When using Mark as Error,
A reason must be entered.
Using skip button allows user
To leave screen without making
Changes.
Display I & O
Shift times in columns link to
additional information
T indicates a comment was added
Sources marked exclude will not
show in the total
CMST Checks
Restraint Documentation
CMST Checks
Change date/
time as needed
to reflect
required q 2
hour restraint
documentation.
Document Restraint data here
Items click yes
require description
Document interventions
every 2 hours and add
comments as needed
Click update complete
to store data
Chart Assessments
Admission/Shift/Focus
Assessment
Create New Assessment
Date and time
should reflect
actual date and
time assessment
was performed.
Select assessment type and click begin
LVNs do not have discharge assessment listed.
Admission Assessment
Selecting ‘Required Assessments’ automatically selects all
the Admission History, Body Systems, Fall Risk, and
Education. Others may be selected as needed. Each system
displays in the order they appear on this screen.
Last chance to modify date and time.
From this screen document Admission History,
Admission assessment, and other
needed assessments, ie, pain/ comfort or restraints.
Select chart detail to continue
Admission History
Ask the patient each question in the admission
history. Only applicable data is actually entered
into the system.
Arrival Date/Time must be entered
Opt Out is a mandatory field
‘…’ indicates additional screens
will appear if the item is selected
Admission History
Personal Belongings
You must describe clothing, cash, jewelry, other
Use these buttons to
move between screens
Location is mandatory
if the field is selected
Admission History
Nutritional Screening
Not required but useful information
Selecting any of these
will send a consult to
Nutrition Services
Admission History
Chaplain Referral
Selecting chaplain referral will generate consult
These fields are mandatory.
Cannot move forward
until completed
Admission History
Continuum of Care
Anticipated discharge placement
Selecting any of these will
generate a referral
Admission History
Advance Directives
Executed Advance Directives is a required field
Admission History
Past Medical/Surgical History
This screen allows you to collect data regarding
existing conditions that may affect the care
during this admission.
Be sure to assess immunization status on admission
Click on Pneumo/Inf to access the Admission Assessment
Hospital Order form and immunization information.
Enter date of vaccination if known,
You can check DWP for immunization date
status if unknown.
RN’s – select
continue to
move on to
physical
assessment.
LVNs may only select Update Pending
Update Complete will be grayed out
Assessment
Within Defined Limits (WDL)
“WDL All” indicates your assessment meets the defined limits
Select “except for” to document exceptions to WDL.
Assessment
Cardiovascular
Most selections can be entered via the point and click method using the radio buttons,
Checkboxes and free-text data entry fields
Assessment
Edema
Click the “Grade” button
for definitions
Assessment
Braden Scale
Braden scale must be assessed every 24 hours
Document any skin abnormality from this screen
Braden Scale
Select either tab or button
Select appropriate descriptor
or free text number in box
Click “Close” or “Continue”
to see Braden total score
Click here to access skin care policy
Assessment
Fall Risk
You must select either
“no fall risk” or one or
more of the risk factors
listed to proceed.
Click here to access fall
prevention guidelines.
Assessment
Storing Data
Assessments that were
visited are underlined
Select update/complete or update/pending
to save entered data
Shift/Focus Assessments
Admission History not an option on this
screen
Required assessments include body systems,
fall risk and education
Other options, ie, Peripheral IV, Pain/Comfort,
etc. may be added as appropriate
All other steps are the same as the admission
assessment
Shift/Focus Assessments
If Shift or Focus Assessment is selected this screen will
appear. Admission History is not an option. ‘Required
Assessments’ automatically selects all the Body Systems,
Fall Risk, and Education. Others may be selected as needed.
Each system displays in the order they appear on this screen.
Select chart detail to continue
View Assessments
Click to view assessment, select assessment
and click view.
View Assessment
This is how data
displays when
View Assessments
selected
Change/Delete Assessment
Select the assessment to be changed
or deleted, then click the appropriate
button for that function.
Change Assessment
Only change your own assessments
Guidelines for Change Assessment
Use Change when you need to modify
an existing assessment that you have
created. This will not create a new
assessment or change the date and
time of the original assessment.
Delete Assessment
This is the final screen before you delete an assessment
Only delete your own assessments.
Guidelines for Delete Assessment
Use Delete when you have charted on
the wrong patient.
Delete only your own assessments
Copy Assessment
Select copy an existing assessment
Select assessment to be copied.
Click copy.
Guidelines for Copy an Existing
Assessment
Use Copy when you want to create a new
assessment based on a previous assessment of
the same type. For example, you need to perform
a Respiratory Assessment every four hours. Select
‘Copy an Existing Assessment’. Then, select the
assessment you wish to copy. Review the
information in the assessment and change those
values that are different from the previous
assessment. This will create a new assessment but
not alter the assessment that was copied.
Complete Pending Assessment
Select complete assessment,
choose assessment in pending
status (P), and click complete.
Discharge Assessment
Enter date/time the patient left the unit.
Not the time of the discharge order
Click continue to move to next screen
Discharge Assessment
Document discharge education,
patient response, and pain status at
time of discharge
This question
asks if
immunization
status was
assessed.
Indicates
administration
of vaccine
Patient Notes
Patient Notes is the opportunity to include a narrative note referring to patient care issues not
addressed by any assessment pathway.
Ex. Response to treatment, untoward events—falls, codes, etc.-- or Nursing Diagnoses not addressed
in assessment pathways
Take ever opportunity to learn.
Be safe out there!