EDUCATION AND PERFORMANCE
Fabio Tricomi
Associate Manager for Medical Education and Performance
Rainbow No #53 7673
Mobile: +44 (0) 7721500260
E-mail : Fabio.Tricomi@msccm.co.uk
SEACARE INPATIENT MODULE
Inpatient services are generally provided for individuals with critical or complex medical
conditions that require around-the-clock care, diagnostic tests, or specialized treatments that
cannot be performed on an outpatient basis. When a patient is admitted as an inpatient, it
means they stay for an extended period within the healthcare facility (more than 4 hours) to
receive continuous medical care, monitoring, and treatment.
We are going to look at two scenarios:
1. Immediate inpatient encounter
a. The immediate Inpatient option is chosen when a patient presents to the medical
centre (or is brought down by the first responder) with a clinical condition that will
require prolonged care. Examples will include suspected fractures, seizures, chest
pain, syncope and heads injuries.
b. Once the patient is identified, Press the green START button:
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MSC –CPD Inpatient Module
c. Your next screen will be the START ENCOUNTER screen.
i. CASE: Start a new case
ii. PHYSICIAN: Choose treating physician
iii. DATE AND TIME: Enter data
iv. TYPE: choose INPATIENT
v. Nurse: choose admitting nurse.
vi. Press Green START button
2. Switching from Outpatient to inpatient.
a. The majority of patients in the medical centre will have been created as an outpatient
encounter. Mr. Amancio - a fictional patient – is an active OUTPATIENT ENCOUNTER,
but during his time in the medical centre, the doctor has decided to admit him for
overnight observation.
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MSC –CPD Inpatient Module
b. To move from and OUTPATIENT to INPATIENT:
i. Click DISPOSITION
ii. Choose either of the below options:
▪
ADMIT TO THE MEDICAL CENTRE, MED SURG
▪
ADMIT TO THE MEDICAL CENTRE, HDU
▪
ADMIT TO THE MEDICAL CENTRE, ICU
iii. Note, whatever has been documented in this outpatient case will remain in
the new INPATIENT module when you transfer this patient.
iv. Click SAVE
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MSC –CPD Inpatient Module
v. Return to the patient's CHART
vi. Click Green START button to start A NEW ENCOUNTER
vii. Select the outpatient case you have just been working on.
viii. Select INPATIENT encounter
ix. Click green START button
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MSC –CPD Inpatient Module
SEACARE INPATIENT FUNCTIONALITIES
•
Now that you are in the inpatient encounter, you will notice a few differences between
the inpatient encounter and the outpatient encounter.
•
Encounter Summary
o
o
Consists of the following sections:
▪
Management
▪
Summary
▪
Charts.
The management section gives you a view of the vitals and the physician/nurse
orders that are still active.
o
The summary section summarizes the encounter including doctor’s notes, nurses’
notes and orders.
o
•
The charts section gives us an overall picture of the recorded vitals.
Vitals:
o
The main vital chart.
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MSC –CPD Inpatient Module
o
SeaCare allows you to insert multiple vital parameters and generate an
electronic chart.
▪
There is also a section for ventilator settings, fluid balance and
neurological.
▪
Remember, anything that you add on this view, it will be viewable in the
summary under the charts we mentioned before.
•
Assessment:
o
Assessments are done either by the nurse or whomever is overseeing the patient.
o
The assessment function is very useful, for instance, when you need to record
hourly neuro-obs as per clinical plan.
o
Go to:
▪
Assessment left hand side tab
▪
Click Assessment (green box)
▪
Select the assessment you would like to document.
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MSC –CPD Inpatient Module
o
Let's say that you would like to record a neuro-obs assessment at 5:30pm: how is
this patient neurologically?
▪
o
Are they oriented to person place in time?
You can also do the same for other systems such as Respiratory, Genitourinary,
Cardiovascular and so on.
o
For each patient admitted to the medical centre, few mandatory risk
assessments should be completed such as: - risk of pressure sores, risk of falls and
VIP score.
•
Hand-over
o
"Handover" refers to the process of transferring patient care from one healthcare
provider to another, typically during shift changes.
o
It is a critical communication process that ensures the continuity and safety of
patient care.
o
This process is straight forward in SeaCare:
▪
Left hand side: Summary
▪
Right hand corner: Hand-over:
▪
The owner and the receiver nurses/doctors will sign and close the tab.
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MSC –CPD Inpatient Module
•
DISCHARGE
o
The "discharge of a patient" refers to the process of releasing a patient from the
onboard hospital, after their treatment or stay has been completed.
o
You need to enter a DIAGNOSIS as we do for outpatient cases.
o
If you have two encounters that have not been closed, because – for example we converted an outpatient encounter to an inpatient, you will see two visit
types available in the master service.
o
In our fictional case of Ms. Lara, the first encounter that was started at 21:25 UTC
+01.00 was a doctor’s consultation in cabin/on scene
o
You can also have a second doctor's visit type here, which means that the
patient had to be admitted to Medical Center AT 21:26 UTC+01.00.
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MSC –CPD Inpatient Module
o
These should reflect on your bill with the right values associated to them, and the
medical fees associated to them - it will reflect what your system administrator
has provided.
•
General Overview:
o
When looking at the CLINIC view, note that inpatients have their own tab so all
the admitted patients will appear under the inpatient tab with some information
about - their demographics, their conditions and the vital signs (including the
MEWS score).
o
So here we can see a list of all the patients that I currently have in my sandbox
environment:
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MSC –CPD Inpatient Module
It's important to note that if patient encounters do not close an inpatient encounter will stay
open until they are closed.
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MSC –CPD Inpatient Module