TCF Day02 MedicalPt 001

TRAINING
TrakCare Fundamentals Day Two

Medical Patient Journey
Document details
Title: TrakCare Fundamentals Day Two Medical Patient Journey
Description: This document is a Training Exercises booklet for a Learning Services

training course.
Version: v5.03
Export URL: https://usconfluence.iscinternal.com/x/gqDSCw
Copyright © 2021 InterSystems Corporation. All rights reserved.

This document is confidential and proprietary. Printing renders document uncontrolled.
TrakCare Fundamentals Day Two Medical Patient Journey v5.03

Confidential and proprietary. Printing renders document uncontrolled. Page 1 of 56
Contents
1. Day Two Medical Patient Journey ............................................................................................... 2

1.1. Exercise - Emergency Patient Admission .......................................................................... 2
1.2. Exercise – Emergency Patient Triage ................................................................................ 4
1.3. Exercise – Emergency Patient Review by Doctor .............................................................. 7
1.4. Exercise – Emergency Patient Nursing Care ................................................................... 15
1.5. Exercise - Bed Management ............................................................................................ 23
1.6. Exercise – Discharge from Emergency Department ........................................................ 25
1.7. Exercise – Inpatient admission from Emergency Department ......................................... 27
1.8. Exercise – Intensive Care Flowsheets ............................................................................. 29
1.9. Exercise – Inpatient Encounter Record ............................................................................ 37
1.10. Exercise – Inpatient Ward Transfer .................................................................................. 40
1.11. Exercise – Inpatient Ward Management .......................................................................... 43
1.12. Exercise – Inpatient Discharge Planning .......................................................................... 46
1.13. Exercise - Inpatient Discharge.......................................................................................... 51

Document Modifications
Version Date Description of Change Modified By
v0.1 01/06/20 Adapted to MEUI S.Evans
v5.02 29/10/20 ACN to Encounter Record S.Evans
v5.03 19/01/21 Update to MR5 SE and BA

1. Day Two Medical Patient Journey
1.1. Exercise - Emergency Patient Admission

Learning Objectives
 Create a Pre-Admission for the Emergency Department
 Register a patient arrival in the Emergency Department
Scenario
Thomas Connor is a 27-year-old male, he twisted his left ankle recently playing basketball.
Thomas was admitted as a surgical patient under the care of Dr Abraham Altona who is an
Orthopaedic Surgeon. Dr Altona performed an open reduction and internal fixation on his
fractured left ankle. Thomas was then discharged home yesterday to the care of his family.
During the night Thomas became restless and agitated and has developed a high temperature.
He is now complaining of pain at the surgical site despite taking the medications prescribed for
him by the surgeon. His concerned family have called the emergency department for advice, and
have been advised to call an ambulance to transport Thomas to the hospital emergency
department.
You will log on to TrakCare as the Emergency Department clerk at the hospital and record the
pre-arrival details for Thomas. When he arrives, you will then locate his patient registration
details and admit him to the Emergency Department.
Login Role: EMD1CK - Sandra Paterson Emergency Department Clerk
Content / Key Points / Instructions
DO The ED Clerk has just received a call from the ambulance service to say they are bringing a
patient into the hospital with expected wound sepsis and that they expect to arrive in 10
minutes.
Select the Main Menu icon

Select the Pre-Arrival(Find) menu
LOOK The Patient Search screen displays.
DO Search for patient details

Surname: Connor
First Name: Thomas
Sex: Male
Find
LOOK The Patient List screen displays. As the patient has been previously registered in this hospital,
their details display in the list. If the search returned an empty list, the clerk would select the
New button to create a new registration.
DO Select the URN identifier link in the Surname column to select the patient details
LOOK The Patient Details display in a banner and the Emergency Episode Details screen displays.

DO The Clerk enters the expected arrival details:
Expand the Seen accordion.

Arrival Transport: Ambulance - Road
Date Expected: t (for today)
Time Expected: n+10 (for 10 minutes in the future)
Expand the Episode Details accordion.

Presenting Complaint: Suspected wound sepsis
Password: demo
Select Update to save and close the Pre-Arrival details.
LOOK On the Emergency Patients list, the patient displays in the waiting area with Clinical and
Administrative Icon group icons showing indicating that the patient is a Pre-Arrival who needs
their Patient Registration Details Confirmed. The patient will also display in the waiting area
when viewing via the Floorplan view.
DO The patient arrives at the hospital so the ED Clerk completes his registration details
Select the Action Menu icon on the same line as the patient's details in the list.
Select the ED Admission menu from the patient Action Menu.
LOOK The Patient Registration screen displays with the patients' details.
DO After confirming the correct patient has been selected the ED Clerk continues with the ED
admission.
Select the Save & Close button on the Patient Registration details.
LOOK The following message displays - 'Do you wish to confirm the patient details?'
DO Select 'Ok' on this message:

The Patient Detail Confirmed field will be set automatically to 'Yes'.
LOOK The emergency Episode Details screen displays. Some of the information already captured
during the Pre-Arrival workflow displays.
DO The ED Clerk documents the Date and Time of actual arrival into the ED.
Date of Actual Arrival: t (for today)
Time of Actual Arrival: n (for now)
Password: demo
Select the Update button to save and close the Episode Details screen.
LOOK The Patient details display in the Waiting Area and can now be triaged by the Triage Nurse.
The Pre-Arrival and Patient Registration Details Needs Confirmation Clinical and
Administrative icons no longer display against the patient.
DO The ED Clerk selects the Logout link to log off.

1.2. Exercise – Emergency Patient Triage
Learning Objectives
 Document Triage Details for the patient
 Move patient into an Emergency bed
Scenario
The Triage Nurse assesses Thomas Connor and determines that he is not very well, he is
reporting a moderate amount of pain, feels hot to the touch and notes that the symptoms had a
rapid onset. Based on these findings and the observations the nurse assigns a triage category of
Urgent to ensure he is seen soon before his condition worsens.
After taking vital signs, assigning a triage category, and documenting some brief notes, the nurse
then allocates Thomas to an available bed within the Emergency Department.
Login Role: EMD1RN - Mr Xavier Jung Emergency Registered Nurse
DO Select the Action Menu icon for the patient in the Waiting Area on the floor plan
Select the Triage First menu from the Action Menu
LOOK The Triage Details screen displays. Information already gathered by the ED Clerk during the
Pre-Arrival and ED Registration displays.
Triage is the process of sorting patients into different categories and priorities of being seen,
based on their presenting complaint, symptoms, and the potential for their condition
worsening. Triage categories can vary in different regions. The Australian Triage Scale is a 5
point scale:
Scale Number Category Description Time to be seen
1 Immediate resuscitation Immediate
2 Very urgent up to 10 minutes
3 Urgent up to 30 minutes
4 Standard up to 60 minutes
5 Non Urgent up to 120 minutes +
The triage nurse will assess the patient and assign them a triage category based on the
findings of the assessment. If the patient has multiple symptoms, the most urgent clinical
feature will determine the triage category for that patient. A colour can be associated with each
category to help quickly identify the triage category of the patients in a list.
DO The Triage Nurse documents the Triage Assessment findings:

Select the Triage Symptoms link
LOOK The Triage Symptoms screen displays. This can be used to document the different symptoms
the patient is presenting with and help the Triage Nurse determine the appropriate triage

category.
DO Document the Triage Symptom details

Triage Symptom: Unwell adult
Select the Find button.
LOOK A list of common problems displays.
DO Select the problem description:Rapid Onset

Select the Add to Log List Below + button OR select the line where the problem description
displays.
Add other triage symptoms and problems as follows:
Triage Symptom: Fever
Find button
Select the problem description: Adult >16 yrs (>38.5C) unwell
Add to Log List Below + button OR select the line where the problem description displays.
Triage Symptom: Pain
Find button
Select the problem description: Severe Peripheral Acute PS 8-10
Add to Log List Below + button OR select the line where the problem description displays.
LOOK The selected problems are added to the list and have been assigned a category colour and
code. This information can be used to update the Triage Category for the patient.
DO View the problem Adult > 16 yrs (> 38.5C) unwell

Note: The Triage Category is 3 Urgent.
Select the Update the Triage Category button to update the Triage Category for this patient,
with the selected problem's triage category.
LOOK The Triage Symptoms screen closes and the Triage Category is updated with the Triage
Category assigned based on the symptoms with the most urgent category, in this example, 3
Urgent.
The Triage Symptoms link is bold indicating that there is information recorded in this link.
DO The nurse continues to document the triage details:

Triage Date: t (for today)
Triage Time: n (for now)
Chief Complaint notes: Painful and inflamed surgical wound to left ankle
The nurse documents the Observations:

Systolic / Diastolic: 115 / 80
Pulse: 120
Respirations: 22
Temperature: 38.5
Oxygen Saturation: 97
Pain Score: 8
The nurse then completes the triage by entering password and updating the screen.
Password: demo

Select the Update button to save and close the Triage Details.
LOOK A warning message appears between the Patient Banner and the Triage Details component,
because the temperature observation was high enough to flag this patient as having a high
Early Warning Score (EWS).
DO Reason for Override: Known condition Alert noted

Select the Confirm button to record the override and response to the alert.
LOOK You are returned to the start/home page.

Thomas's details in the Waiting Area are now displayed in the list based ordered by triage
category.
A coloured band displays next to his details to indicate the assigned triage category.
A numerical value indicating how much time Thomas has been in the Emergency Department
displays. This number will display in different colours depending on how long the patient has
been in the department without being seen by a Care Provider.
DO The Triage Nurse assigns Thomas to an available bed.

Select Thomas from the Waiting Area on the floor plan.
Select an available cubicle.
LOOK The Bed Movements screen displays showing the selected movement details, including the
start date, time and the bed to which the patient is going to be moved.
DO As this patient is so unwell, the triage nurse anticipates that he may require an ICU admission.
Likely Transfer ICU:Yes
Select Update to save the details and complete the move.
LOOK The patient is now displaying in the selected bed on the floorplan.
DO The Triage Nurse now selects the User Profile and Logout link to log off.
The patient is now ready to be seen by a Care Provider in the Emergency Department.

1.3. Exercise – Emergency Patient Review by Doctor
Learning Objectives
 Assign patient to ED Clinician
 View Encounter Record patient history
 Associate a problem with an Encounter Record entry
 Order from an Order Set
 Document a clinical note
 Annotate an image
Scenario
The on-duty clinician, Dr Terry Murphy, sees Thomas. Dr Murphy records that he is going to take
on the care of Thomas, and that Dr Ed Quigley is the senior Emergency Consultant.
First, he will review Thomas' medical record, and then perform an assessment of the patient.
Based on the findings from the assessment, he will request some orders and document a
treatment plan in a clinical note.
He will also add an image to the notes to help others recognise any changes to Thomas' surgical
wound.
Login Role: EMD1DR - Dr Terry Murphy Emergency Doctor
DO Dr Murphy takes on the care of Thomas Connor.

Select the Action Menu icon on the same row as the patient.
Select the Seen By Dr menu from the menu header.
LOOK The Seen By Doctor screen displays. The Current Date and Time display.
DO Dr Murphy adds the Seen By Doctor details, including the likelihood of admitting Thomas as an
inpatient.
Seen by Care Provider: Dr Terry Murphy
Emergency Consultant: Dr Ed Quigley
Likely To Admit: Yes

Select Update to save and close.
LOOK The start screen displays, and Dr Terry Murphy's details are now displaying next to the patient
to indicate that he is the responsible care provider. There is also a Clinical Info icon alerting
that this patient is likely to be admitted as an inpatient.
DO Dr Murphy now reviews Thomas' record

Select the Action Menu icon on the same row as the patient.
Select the Encounter Record menu from the patient Action Menu.
LOOK The Encounter Record displays. The Patient Summary Chart displays so the doctor can

quickly review the previous medical history and any ongoing care activities.
DO The details that have been previously recorded against Thomas' chart can be reviewed.
View the Patient's History section
Review the Active Problems
Scroll down to the Observations section
View Vital Signs (Last Entry) chart.
LOOK The observations recorded by the nurse during Triage display.
DO Select the EPR Chartbook icon.
LOOK The EPR chartbook displays
1. Any Charts that are empty have no colour indicator displaying next to them.
2. Charts containing a Clinical Profile that may or may not contain data will display a light
grey indicator next to them.
3. Charts that contain information display a dark green indicator next to them.
DO View Doctors Assessment chart

Select the Notes chart tab
LOOK Notes display from previous episodes.
DO Dr Murphy documents the patient problems in the Encounter Record.

Select a new Entry Type: Emergency Clinician Assessment
Select the New + entry icon.
LOOK The Current tab icon becomes active and a new Entry is displays.
DO Dr Murphy documents the Reason for Encounter.

Select the Add Reason for Encounter action link.
LOOK The Reason for Encounter edit screen opens.
DO Dr Murphy documents that the patient has a septic wound.

Description (SNOMED): Septic Wound
Severity (SNOMED): Severe
Create a Problem: Checkbox ON
Main RFE: Checkbox ON
Onset Date: t (for today)at: 0600
Comments: Painful and inflamed surgical wound to left ankle

Select the Update button to save details and close the Infopane.
LOOK A Reason for Encounter and Problem entry note displays in the Encounter Record.
DO Dr Murphy realises that the surgical wound is related to the existing problem 'Ankle Fracture'
and wants to associate this problem with the entry just made.
Select the Action Menu (...) on the Encounter Record Entry header, next to the currently
linked problem of 'Septic Wound'
LOOK The Encounter Record Header action menu displays
DO Select the Link Problems to Entry menu option.
LOOK The Problems list displays.

The newly added problem is displaying with an active Encounter Item Link icon displaying.
Earlier documented problems display with inactive link icons.
DO Locate the Ankle Fracture problem
Select the Encounter Item inactive link icon.
Return to the Current entry by selecting the Back to: UPR breadcrumb link.
LOOK The entry displays and the problem link text now displays on the entry header.
Note: The problem will be added to the top level of the Encounter Record Entry, so will apply
to all items in this entry.
If the individual entry item Action Menu icon is selected, a similar Link Problems to Entry
menu is available, and the problem will be linked to the entry item instead.
DO Doctor Murphy documents a quick Review of System.

Select Extra Action lookup
Select the Add Review of System action:
LOOK The Review Of Systems edit tool displays with a list of Body Systems. Using this tool clinicians
can quickly document if certain symptoms are present by Body System. There are three
decision states for each symptom. Selecting the icon next to the symptom will scroll through
the three different states.
Not asked / NA : The symptom was not relevant or not checked
Negative / NO : The symptom was checked but is not present
Positive / YES : The symptom was checked and is present
If a symptom is not available in the suggested list, it can be added by the clinician.
The Review of Systems (RoS) provides a tool to document subjective findings as described
by the patient. Information is organised in to organ systems, usually in a head-to-toe format. In
some circumstances it may be restricted to the system(s) the presenting complaint involves,

but in less clear-cut cases, it may be reasonable to review some/all other systems in a
comprehensive manner.
The RoS can be used when:
 It is appropriate to document the medical interview findings in a structured manner
 Recording pertinent negatives
DO As this is primarily a Musculoskeletal problem, Dr Murphy selects this system.

Select Musculoskeletal from the Systems list.
LOOK A list of common symptoms related with the Musculoskeletal system displays in the right pane.
Each of these have a decision box next to them defaulting to the 'Not Asked/ Not Applicable '
state.
DO Dr Murphy documents what was seen during the examination of Thomas. Click each of the
following to display the tick or x.
Foot Swelling: Positive
Joint stiffness: Positive
Difficulty moving leg:Negative
Dr Murphy wants to add a more descriptive symptom of 'Swelling of ankle joint'
There is a lookup field below the Suggested Symptom list.
Symptom: ankle joint swell
LOOK The lookup presents all available symptoms containing the search terms 'ankle', 'joint' and
'swell'. An add icon displays next to the lookup.
DO Select: Swelling of ankle joint

Select the Add icon
LOOK The selected symptom is added to the suggested list of symptoms with a Positive indicator.
DO Dr Murphy adds the Review of Systems symptoms to the current entry.

Select Update to save and close the Review of Systems.
LOOK A new entry is created containing the list of selected symptoms.
DO An image of the foot will be added to the Encounter Record
Extra Actions: Add Annotations
LOOK The list of available images from the hospital image library displays
DO Search for the appropriate image:
Image Filename: body_foot
FIND

LOOK The list is filtered by all images that contain the search terms in their file name
DO Select the body_foot_lateral.jpg image filename link
LOOK The image displays in the Picture annotation tool.
DO From the colour pallet, select the RED colour

Select the 'Freehand' drawing tool to draw where the inflammation is obvious on the foot
Text To Add: Inflamed area
(Note: the Text Label tool is automatically selected when Text To Add is entered.)
Draw a label on the image where the text label should display.
Use the Select Tool to select items on the picture canvas and move them around.
Select Update to save the changes and close the Picture Annotation tool.
LOOK The image displays in the Encounter Record page under Examinations.
DO Dr Murphy adds an Assessment Note:

Select the Add Emergency Note (Assessment) action link.
LOOK The Clinical Notes edit info pane displays. Many different types of notes can be created from
this action. In this case Dr Murphy will create a clinical note of 'Emergency Note' type.
DO Dr Murphy adds information to the assessment note. This note type is an example of a
template.
Type: Emergency Notes
Text Edit:
Presentation: 26 year old male with recent surgical wound for ORIF left ankle.
Assessment: Surgical Wound appears to be infected, swelling and inflammation present.
Patient is febrile and deteriorating rapidly. Risk for sepsis.
Plan: Wound swab, re-dress wound and IV antibiotic therapy. Admit to ICU for continuous
observation and monitoring for organ dysfunction.
Dr Murphy wants to add the image directly into the notes:

From the Clinical Notes Edit tool, select the Insert TrakCare Image icon.
LOOK The Pictures, Documentation and Annotations screen opens.
DO Select the link to the image filename under the Annotation Images list section of the screen.
LOOK The Pictures, Documents and Annotations Screen closes, and the image is inserted into the
Clinical Note.

DO Dr Murphy has completed the entry and closes the Clinical Note.
Password: demo
Select the Update button to save the clinical note and return to the Encounter Record entry
screen.
LOOK The Emergency Note is added to the Encounter Record main pane and displays text and
images.
DO Dr Murphy requests some orders from a Sepsis Management Order Set.

Select Add Order action link.
LOOK The Order Entry screen displays.
DO As the Sepsis Management is not in the favourites, Dr Murphy will search for it.
Item: Sepsis Management
Select the expand list arrow from the lookup list.
LOOK The Sepsis Management order set displays. Some items have been selected by default, and
others are unselected, but suggested. There are also advice narratives displaying with the
antibiotic therapy orders.
DO Select the required items:

1/24 hrly vital signs: Checked on
4/24 GSC Glasgow Coma Scale: Checked on
Culture Aerobic: Checked on
Culture Anaerobic: Checked on
Full Blood Count: Checked on
Vancomycin IV 1g Stat Dose: Checked on
Metronidazole IV 500mg: Checked on
Select the Add button.
LOOK The selected items display in the Ordering Cart.
DO Dr Murphy takes note of the requirement to collect the specimens before administering the
medications, and collects them immediately.
Select the Culture Anaerobic order item details link in the Ordering Cart.
LOOK The Order Details display in the Order Entry screen.

A specimen container section displays as part of the order item details.
DO Select the Collected Checkbox to ON
LOOK The Current date and time default into the Collection Date and Time fields.
DO Select the Update button on the Order Details screen to save the collection details.

LOOK The updated items display in the Ordering Cart.
DO Collect the Specimen for the other blood items.

Aerobic Culture
Full Blood Count
Update each of the laboratory order item details to save changes.
LOOK Both the pharmacy items were ordered at the same time - however the Metronidazole order
has a start time One hour after the start time of the Vancomycin order. This is determined by
the sequence that was established against the order set.
DO Dr Murphy wants to review the planned sequence of administration for the drugs he is about to
order from the order set.
Select the Order Set View checkbox above the Ordering Cart.
LOOK The Ordering Cart is re-organised and the name of the order set displays as a heading. This
allows the user to view all items that belong to a particular order set.
DO Select the Sepsis Management order set header checkbox to select all items in the set.
Select the Order Cart Action Menu.
Select the Sequence Plan option from the menu.
LOOK The Sequence Plan screen displays the planned sequence details for this order set, including
planned administration dates and times. If required different items of the sequence plan can be
modified from this screen.
DO After reviewing the planned sequence of administration times the Doctor closes the Sequence
Plan screen,
Select Update to close the screen and return to the Order Cart.
LOOK The Ordering Cart displays, the order set items are still selected.
DO Using the Order Favourites function, Doctor Murphy also prescribes an anti-inflammatory and
pain relief to be administered PRN (as required) every 4 hours, ongoing, for pain,
inflammation and fever.
Select the Order Favourites star icon in the Order Entry Toolbar
Select the Medications accordion from the Favourites Catalogue
Select the Others accordion
Locate the Paracetamol + Codeine 500mg +30mg tablets order favourite.
Select the Order Details icon (pencil)
LOOK The details are added to the Ordering Cart and the details display in the Medication Order
Details screen.
DO Adjust the defaults to suit this patient.

Frequency: Every 4 Hours

PRN: Checkbox ON
PRN relevant fields display:
Maximum QTY in 24 hours:8 tablet(s) every 24 hours
PRN: Indication for:Pain, inflammation, fever.
Duration Options: Ongoing
Select Update to save changes to Order Details screen.
LOOK The details in the Ordering Cart have updated and reflect the changes. The Order Set View
checkbox is still active, so the Codeine and Paracetamol order that were ordered separately
from the order set display under a different order category header of 'Pharmacy'.
There is an Alert displaying for a Therapeutic Duplication - this is due to the order from the
previous day for morphine and Sodium Lactate not being discontinued.
DO Select the Messages and Alerts Details icon in the Order Entry Toolbar to review the alert
information.
Select the Order details the override relates to, by selecting the checkbox next to the details
in the Messages and Alerts list.
Reason for Override:Alert noted and order required
Select Update Alerts button in the button bar.
LOOK The Alert clears and the order can now resume. The order cart displays.
DO Dr Murphy has completed the orders for this encounter.

Password: demo
Select Update to save and close the order entry screen.
LOOK The order details display on the Order Summary screen.
DO Select Update on the order summary screen.
LOOK The order details display in the Encounter Record screen.
DO Lock your entry.

Dr Murphy selects the Logout link to log off.

1.4. Exercise – Emergency Patient Nursing Care
Learning Objectives
 Administer medications
 Create an inpatient bed request
 View inpatient bed request status
Scenario
A Registered Nurse checks the tasks that have been requested for patients in the emergency
department. After checking the list, he notices that there are some drugs ordered for Thomas.
The Registered Nurse then reviews Thomas' chart, administers the medications and creates an
inpatient bed request to alert the bed manager that a bed is required in the Intensive Care Unit
for Thomas.
Login Role: EMD1RN - Mr Xavier Jung, Emergency Registered Nurse
DO Select the Main Menu icon
Select the Nurse Tasklist menu from the Main Menu.
LOOK The Nurse Tasklist displays showing indicators for when tasks are due against patient's
details. Thomas' details display with indicators showing that he has some medications and
care activities.
DO Select the indicator for Medications (small capsule icon) in the row for the patient
corresponding with the current time column.
LOOK The Clinical Profile for the patient displays. The requested medications display. Some are due
in the current time band column.
DO Select the administration link (dose and time) for the Vancomycin 1g in Sodium Chloride
0.9% order.
LOOK The Admixture Manufacturing screen displays
Some medications cannot be stored for extended periods of time without becoming unstable
and ineffective. These medications must be 'manufactured' or reconstituted close to the time of
administration. As this will often require a powder like substance being added and mixed with a
liquid solvent, these are referred to as 'Admixtures'. These can be created or 'manufactured' by
the pharmacy or in some cases by the registered nurse on the ward at the bed side
immediately prior to administration to the patient.
LOOK An Admixture Stock Selection list displays showing the ingredients required for the admixture
recipe.
Sodium Chloride is the solvent, which will be used to dilute and administer the medication.
Vancomycin is the medication that will be added and mixed with the solvent.

The first ingredient has defaulted into the search fields.
DO Select the items from the stock cupboard

Select the admixture item used.
Prescribed Item: Sodium Chloride 0.9% infusion(defaults)
Location:Emergency Department (defaults)
A list of available pharmacy items displays below the Available Stock find fields
Admix Item:Select the sodium chloride infusion 250ml bag link
LOOK The screen reloads and the selected item and location is added to the Admixture Stock
Selection list. The focus shifts to the next item in the admixture stock selection list. All available
matching items are displaying on the admixture items list.
DO Prescribed Item:vancomycin 1g/vial powder

Location:Emergency Department
A list of available pharmacy items displays
Admix Item:Select the Vancomycin, powder for concentrate link
LOOK The selected item now appears in the Admixture Stock Selection list. As all stock items have
been documented, the Proceed button becomes active.
DO Select Proceed button to confirm the admixture
LOOK The Complete Nurse Manufacture page displays with the details of the selected items being
combined in the admixture recipe.
DO The nurse documents the completion of Admixture Manufacture

Expiry Date: Today
Expiry Time:N+180 (3 hours in future)
Update
LOOK The Medication Administration screen displays. The Registered Nurse reviews the
administration details and verifies that the correct drug, is being administered to the correct
patient in the correct dose via the correct route within the correct time-frame.
The Nurse Manufacture Details display showing a Batch number for the manufactured
admixture.
The medication can now be administered, and the administration documented.
DO The Registered Nurse documents the administration of the medication.

Order Execution Started By:Mr Xavier Jung
Password: demo
Select the Update button to confirm the administration details are correct and complete the
documentation.

LOOK The Clinical Profile displays again showing that the Vancomycin order has a status of 'Started'.
DO The Nurse decides to administer the co-codamol (codeine and paracetamol) as the patient
was febrile and experiencing pain.
Select the PRN link in the time column for the Paracetamol order.
LOOK The administration screen displays for the PRN co-codamol order. Some information is
required on this screen before the drug can be administered.
DO Complete the fields required to administer the medication.

Executed By: Mr Xavier Jung
Administration Status:Administered
PRN Reason: Pain and fever
Alternate Dispensing Dept:CLEAR THIS FIELD
Signatures section:
Password: demo
Select Update to record the administration of the medication
LOOK A medication administered icon displays in the Clinical profile against the administered PRN
medication, and the next available administration time displays as an 'Unavailable' hyperlink
- the administration screen will not become available until closer to the administration time.
An Administration Summary icon displays below the order details and will allow the
clinical users to view a summary of the administration history for this medication item.
DO The Registered Nurse will check for any other tasks due to be performed.
Select the Back to: Nurse Tasklist breadcrumb link.
LOOK There are some Care tasks due to be completed (represented by the Medical Bag icon).
DO
Select the indicator for a Care type task .
LOOK The Clinical Profile screen displays with the requests for Observations to be performed.
DO Select the next due time for the 1/24 hrly vital signs.
LOOK The observation edit screen displays. With the vital signs fields available for entry.
DO Select a time link. The Registered Nurse documents the vital signs in the record.
Systolic: 110
Diastolic: 60
Pulse: 85
Respirations: 22
Temperature: 38.2
Oxygen Saturation:98

Pain Score: 7
Date Administered: T (today)
Time Administered: N (now)
Administration Status: Attended

Password: demo
Select the Update to save the observation values and close the entry screen.
LOOK A warning displays alerting the Registered Nurse that these observation values have triggered
a Critical EWS (Early Warning Signs) message. The Registered Nurse will have to
acknowledge the warning and record what action is being undertaken to continue with the
entry.
DO Acknowledge the warning message:

Reason for Override: Known condition - Alert noted
Comment field: Clinician made aware of patient condition
Select the Confirm button to acknowledge the message and continue.
LOOK The Clinical Profile displays. A status of 'Attended' displays against the time link previously
selected on the Clinical Profile screen indicating that the observations have been entered for
this time.
DO The Registered Nurse will now review the patient notes:

(With the Clinical Profile Care chart still open)
Select the patient Action Menu icon in the patient banner.

Select the Encounter Record menu from the available menus.
The Encounter Record is a menu that requires a patient to be in focus when it is selected. As
the menu is accessed from the patient banner, the patient details can be checked before
selecting it.
LOOK The Encounter Record screen displays. As there is no active entry by this user the Patient
EPR Summary chart displays.
DO Use the arrow next to the Patient Summary chart to close the tab
Select the EPR icon from the Encounter Record
Select the Doctors Assessment chart tab
LOOK The entry for the Emergency Note displays in the All Notes chart.
DO
Expand the HTML Notes arrow next to the Edit icon
LOOK The complete note displays within the notes area.

DO Select the Back to UPR link
Select the New Entry icon
Open a New Emergency Nurse Assessment entry type.
Select the New Encounter Entry icon for: Emergency Nurse Assessment.
LOOK A new Encounter Record entry opens.
DO The nurse commences a Nursing Care Plan
From the actions, select the Add Nursing Care Plan action
LOOK The Nursing Care Plans Wizard opens - by default a nursing care plan assessment tool
displays.
DO Due to the pain relief medication that this patient is using, the nurse evaluates that he is at an
increased risk for constipation
Under the Elimination Pattern section accordion
select the Constipation 'Yes' checkbox
Select the Next button
In a typical nursing plan assessment, a more thorough documentation would be completed -

but for demonstration purposes - we will just document this one item.
LOOK A list of Suggested Nursing Problems displays
DO Select the 'Constipation' checkbox
LOOK The Problem Identification screen displays with the Constipation problem now listed in the
Active Problems list. Links that display Interventions and Outcomes for the problem of

Constipation display.
DO Select the Next button
LOOK A list of the Problem Details for Constipation display
DO Select 'Abdominal Pain' checkbox
LOOK A suggested list of interventions displays
DO Select the Constipation/Impaction Management intervention checkbox
LOOK A list of nursing activities for managing the problem display
DO Select the activities
LOOK The Outcome identification screen displays
DO Complete the Outcomes that will be used to evaluate the progress of the patient in reaching
this nursing goal
Bowel Elimination - Check box ON
Goal: - 5
Within: 2 - Days
Monitor Every: - 1 Days
Outcomes are measured on a scale of 1 to 5 - with 5 being the most desirable outcome
LOOK The suggested Interventions to achieve the outcome display
DO Select Bowel Training and Bowel Management checkboxes
LOOK The Activities for the first intervention display
DO Select the first 2 activities

LOOK The Activities for the next intervention display
DO Select the first activity
LOOK The Review and Confirm screen displays - the different steps of the plan display as links on
the left side of the screen.
DO Select the Start Plan button
LOOK The Nursing Care Plan wizard closes and the Nursing Care Plan Tools displays with all the
nursing care plan activities listed.
DO The Registered Nurse creates a Bed Request to admit Thomas into the Intensive Care ward.
Return to the Encounter Record
Select the Back to: UPR menu

Select the Add ED to IP Admission Request action link.
LOOK The Bed Request screen opens.
DO Complete the Bed Request details

Inpatient Unit: Intensive Care Medicine
Inpatient Consultant: Dr Bill Paladino
Expected Length of Stay: 8 Hours
ICU Bed Required: Checkbox ON
Note: When the Expected Length of Stay was entered the Expected Date of Discharge IP
Episode auto populated today's date.
Select the Update button to save the details and close the screen.
LOOK The IP Admission Request details display in the Encounter Record.
DO The Registered Nurse views the homepage.

Select the Home link to return to the start screen.
LOOK The Floorplan displays. The patient displays with an icon indicator alerting that there are
Administrative Details that require attention.
DO Select the Administrative Details icon to view the details in the icon profile.
LOOK The icon group displays.

There is a notice that a bed has been requested - and the requesting department name.
DO Select anywhere in the main screen to close the icon information profile.

The Registered Nurse uses the Logout link to log off the system.

1.5. Exercise - Bed Management
Learning Objectives
 Review current status of inpatient wards
 Review outstanding bed requests
 Approve bed requests and create pre-admission
Scenario
The Bed Manager is tasked with ensuring that all patients requiring a bed are allocated to the
appropriate ward. The Bed Manager reviews a summary list of the current bed requests for the
hospital and reviews the request to admit Thomas Connor into the Intensive Care Unit for 8
hours of intensive monitoring.
After reviewing that the ward has capacity and the appropriate resources, she authorises the
requests and creates a pre-admission booking for Thomas so that he can be admitted today.
Login Role: PAS1BM - Miss Ying Lee, Bed Manager
LOOK The Bed Manager start screen is the Ward Summary List.
From here they can see the expected admissions and discharges.
The Preferences button allows the information displayed to be customised for the user.
DO Select the Floorplan icon for the Intensive Care W1 ward.
LOOK The floorplan displays showing occupied and available beds.
DO The Bed manager reviews the incoming Bed Requests via a summary list.
Select the Main Menu icon

Select Bed Request Summary menu from the main menu.
LOOK The Bed Request Summary screen displays. This contains three different lists.
Requests with no wards: All incoming requests that have not had a ward allocated to them
Requests from Emergency and ICU Wards: All requests from Emergency or ICU, with and
without a ward allocated.
Requests from all wards: Requests from anywhere in the hospital that have a ward
requested but need to be accepted.
DO The Bed manager reviews the Request details for Thomas Connor
From the Requests from Emergency and ICU wards section.
Locate the request for Thomas Connor.
Select the edit icon under the Request column against his details.
LOOK The Bed Request screen displays.
DO The Bed Manager allocates Thomas to a ward and a bed.

Ward: Intensive Care W1

Expected Bed Length of Stay: 8 Hours

Booked Location is Ready: Checkbox ON
Create Preadmission: Checkbox ON
Select the Update button to save the changes and close the screen.
LOOK The Bed Request Summary list refreshes and the details of the allocated ward display against
the patients' entry.
NOTE: to refresh all three lists, select the Bed Request Summary menu - the updates will
then be reflected in the other Request Lists on the screen.
DO The Bed Manager selects the Home link to return to the Ward Summary List.
Select the floorplan icon for the Emergency Department ward.
LOOK The patient details display on the floorplan, if the Administrative icon group is selected, the
Bed Request details have been updated to: Location is ready but no bed assigned: Intensive
Care Medicine: Intensive Care W1.
DO The Bed Manager selects the Home link to return to the Ward Summary List.
Select the floorplan icon for the Intensive Care W1 ward.
LOOK The patients' details are displaying in the Nursing Station of the Intensive Care ward. This
alerts the staff that he has a booking to come into the ward, and to prepare the room for him.
Although the patient details display on the inpatient ward floorplan - it is just an indication to
the ward staff that the patient has a booking and will be arriving soon - The patient is physically
still located within the Emergency Department and will stay there until the emergency episode
is discharged.
DO The Bed Manager uses the Logout link to log off.

1.6. Exercise – Discharge from Emergency Department
Learning Objectives
 Prepare patient for discharge to ward
 Discharge patient to inpatient ward
Scenario
The Registered Nurse notices that the bed request for Thomas Connor has been approved, and
so prepares to discharge him from the Emergency Department into the care of the Intensive
Care unit.
Login Role: EMD1RN - Mr Xavier Jung, Emergency Registered Nurse
When a patient leaves the Emergency Department they are discharged, even if they are not
physically leaving the hospital. Using this workflow will ensure that any orders that were placed
during the Emergency Episode of care will be transferred with the patient to the new location.
DO Select the patient Action Menu icon for Thomas Connor from the floorplan.
Select the Encounter Record menu from the Action Menu.
LOOK The previous entry is still open, there is a red indicator next to the ED Admission Request
entry and a warning message to indicate that there has been a change to this information after
the entry was made i.e. the Bed Manager created the pre-admission and allocated a ward and
bed.
The entry can be selected to view the changes to the Bed Request.
DO The Registered Nurse creates a Planning Note.

Select the Add Emergency Note (Planning) action link.
LOOK The Clinical Notes screen displays
DO The Registered Nurse documents a discharge summary.

Care Provider: Mr Xavier Jung
Type: Emergency Note
Note Text: Patient is to be transferred to the ICU,
Intravenous infusion insitu and patent.
ICU ward contacted and aware of the transfer.
Password: demo
Select the Update button to save and close the clinical note.
LOOK The details display in the Encounter Record.
DO The Registered Nurse completes the ED Discharge.

Select the Add ED Discharge Request action link.

LOOK The Booked ward information displays at the top of the discharged details screen. Note: there
are three sections - Estimated Discharge Details; Medical Discharge Details; Final Discharge
Details.
Medical Discharge is used if a doctor verifies that the patient is medically fit, but may not be
ready to be physically discharged (waiting for appointments, medications, transport etc).
DO The Registered Nurse verifies the Discharge Information

Final Discharge Details section
Ward Booked: Intensive Care W1 (defaults)
Final Discharge Details
Discharge Date: t (for today).
Discharge Time: n (for now).
Handy Hint: use the close accordion arrows to navigate to the bottom of the screen.
Password: demo
Select Update to save the changes and discharge the patient.
LOOK The Encounter Record entry displays.
DO Lock the current Encounter Record entry by selecting the open padlock in the entry banner.
Select Home to return to the Emergency Department floorplan.
LOOK The bed that the patient was in is now closed for cleaning and has a time displaying for when it
will be available again.
DO The Registered Nurse will check the bed has been cleaned and make the bed available for
use again.
Select the Bed Code hyperlink at the top of the bed space.
LOOK The Bed Status Change details display: This has two sections: a Bed Status Change edit
section and a Bed Status Change list section.
The details of the current Cleaning state display in the list section.
DO Select the Start Date link against the current cleaning details in the list.
LOOK The current cleaning details display in the edit section, top of the Bed Status Change screen.
There is an End Date and Time entered, but these are in the future. This is determined by a
predefined parameter.
DO To override the default details to record the actual time the bed is available (now).
Clear the End Time field and enter the current time.
Select Update to save the changes and close the Bed Status Change details screen.
LOOK The Floorplan refreshes and the bed is now available for the next patient.
DO Logout

1.7. Exercise – Inpatient admission from Emergency Department
Learning Objectives
 Register patient recently arrived from Emergency Department
Scenario
Thomas Connor has now arrived in the Intensive Care ward - and his booking details display in
the booked patient area of the ward.
The Clerk in the Intensive Care Ward notes that he has been assigned to a bed and registers the
patient as arrived on the ward.
Login Role: ICU1CK - Ms Harriet Brown, Intensive Care Ward Clerk
LOOK The Ward List displays:

The patient displays with an orange indicator against his details indicating that he is an
admission booking from the emergency department.
DO Select the patient Action Menu icon next to Thomas Connor from the ward list within the
Patients in Waiting Area.
Select the IP Registration menu to admit him to the ward.
LOOK The patient demographic details display - so the inpatient clerk can confirm that the correct
patient is being admitted, and update any details required for the admission.
DO The Clerk reviews the Patient Registration details.

There are no changes to be made at this time.
Select the Update button to close the screen and move to the next step in workflow.
LOOK The Episode Registration details screen displays.

The details from the request for admission have defaulted through into the details. The date
and time the patient was admitted to the Emergency Department is the date and time that
defaults into the Episode start details.
DO The Ward Clerk reviews the details and assigns the patient to a bed.
Bed Code: select an empty bed from lookup list.
Select the Update button to close the screen and move ahead in the workflow.
LOOK The Payor Details screen displays.
DO The Ward Clerk reviews the billing details. For the moment there is no Payor information to
record.
Select the Update button to move to the next screen in the workflow.
LOOK The Patient now displays in the Patient in ward list, assigned to the bed.

DO The Ward Clerk uses the Logout link to log off from the environment.

1.8. Exercise – Intensive Care Flowsheets
Learning Objectives
 Overview of ICU Flowsheets
 Record Observations via ICU Flowsheets
 Add an observation item to ICU Flowsheet profile
 Record Assessments via ICU Flowsheets
 Record IV Administration via ICU Flowsheets
 Document the Fluid Balance via ICU Flowsheets
 Document a clinical incident via ICU Flowsheets
Scenario
The Registered Nurse accesses the ICU Flowsheet to record a set of baseline observations for
Thomas Connor.
Login Role: ICU1RN - Mr Dan Gomez, Intensive Care Registered Nurse
DO Select the patient Action Menu for Thomas Connor from the floorplan.
Select the Flowsheet menu from the menu header.
LOOK The ICU Flowsheet displays with the Vital Signs summary chart open.
Actions display as blue buttons down the left hand side of the screen.
Chart profiles display across the top of the observations graph.
The current time displays as a red vertical line on the right side of the timeline.
DO The Registered Nurse attaches the patient to the monitors and records the first set of
admission observations.
In the Vital Signs column on the observations grid select the '+' icon next to the New link.
LOOK The HDR Vital Signs manual entry screen displays (In a live site with electronic monitoring
these would be linked to automatically populate)
DO Manually record the observations

Eye Opening: 4- Spontaneously
Motor: 5- Localizes to Painful Stimuli
Verbal: 4- Confused, Disoriented
Pulse: 85
Systolic: 110
Diastolic: 68
Temperature: 37.8
Respirations: 22
Password: demo
Select Update to save the values.

LOOK The recorded observation items display on the graph and input grid.
DO The Registered Nurse wants to remove the unused observation items from the grid display
and add a new observation item to document observations for the patients' infected wound.
In the Vital Signs column on the observations grid select the '+/-' icon next to the New link
LOOK The Patient Observation Preferences screen displays.

The Registered Nurse can suspend observation items using the settings on this screen. Items
with the value 'SYS' ticked next to them are the default items supplied by the 'system'. The
Low and High Ranges for the observations items can also be adjusted on this page.
DO Suspend the unwanted observation items.
RASS: Suspend Checkbox On
ABPS (Arterial Systolic): Suspended Checkbox On

ABPD (Arterial Diastolic): Suspended Checkbox On
Mean Arterial Pressure: Suspended Checkbox On
Central Venous Pressure (CVP): Suspended Checkbox On
Stroke Volume: Suspend Checkbox On
Blood Glucose: Suspend Checkbox On
FiO2: Suspended Checkbox On
ET-CO2: Suspended Checkbox On
ICP (Inter Cranial Pressure): Suspended Checkbox On
Ectopy: Suspend Checkbox On
CPP (Cerebral Perfusion Pressure): Suspended Checkbox On
Add a new observation item for the Infected ankle wound.

Observation Item: Wound Comments
Unique Code: Infected ankle wound
Select APPLY
LOOK Two items have been added to the HDR Vital Signs list -
Wound Comments:
and
Wound Comments {Infected ankle wound}
The first item is a 'system' generated item - the second one is the unique code item based on
the system observation item - Only one is required.
DO The Registered Nurse suspends the System based value so only the unique observation item
will display:
Wound Comments: Suspended Checkbox On
The Registered Nurse has also noted that this patient has a pulse and blood pressure that is
below the set Low Range - this is causing the alerts to trigger too frequently, and as Thomas is
typically a healthy young male, the nurse decides to adjust the Low Range to reflect a more
accurate risk profile.
Pulse: Low Range: 65
Systolic: Low Range: 115

Diastolic: Low Range: 68

MAP (Mean Arterial Pressure): Low Range: 80
Select Update to save and the changes and close the Patient Observation Preferences
screen.
LOOK The observations grid displays with the suspended items removed and the new observation
item for the wound infection added.
DO The Registered Nurse records another set of observations:

Select the New observations icon on the Vital Signs column.
LOOK The HDR Vital Signs observation input screen displays. Suspended items no longer display on
the input screen. The newly adjusted Low ranges display.
DO The Registered Nurse enters the observation values:

Pulse: 70
Systolic: 125
Diastolic: 75
Temperature: 37.5
Respirations: 15
Wound Comments: (Infected Ankle Wound): Red Inflamed ankle
Password: demo
Select Update to save the observation values and close the observations input screen.
LOOK The newly added observation items display on the graph and the input grid.
The EWS warning was not triggered as there are not items displaying outside of the newly
adjusted parameters.
DO The Registered Nurse wants to document a Wound Management assessment form to evaluate
the ankle wound.
From the ICU Flowsheet Task buttons
Select the ICU Care Assessments task button.
LOOK The available ICU Care Assessment chart profiles display. The Wound Management chart is
the second available chart.
DO Select the Wound Management chart tab.

Select the Wound Management profile New icon
(Note: the accordion may need to be expanded)
LOOK The Wound Management questionnaire opens. The Registered Nurse can record an
evaluation of the wound. This questionnaire is designed for cumulative information collection,
so that information about the wound being assessed can be collected and compared over
time.

DO The Registered Nurse documents the Wound Management details

Wound Site: (L) Lateral ankle
Type of Wound: Surgical
The Registered Nurse documents the Evaluation details
Date: t (for today)
Size right/left - top/down: 1mm
Edges: Attached
Undermining: None present
Exudate: Nil
Wound Infection:(select from list box lookup) Red, Heat, Increased pain
Granulation tissue: Skin intact or partial thickness
Skin colour surrounding: Bright red
LOOK The details are added as a row to the Evaluation details list
DO Close the Evaluation accordion by selecting the small black arrow on the accordion.
The Registered Nurse documents the Treatment details
Date: t (for today)
Time: n (for now)
Pain prevention: Prescribed treatment
Care: (select from list box lookup) Cleaning, Sodium chloride
Type of Dressing: Cover air permeable
Note Area: Left leg elevated.
LOOK The details are added as a row to the Treatment details list.
DO Close the Treatment accordion by selecting the small black arrow on the accordion.
The Registered Nurse documents the Pain Assessment details
Date: t (for today)
Time: n (for now)
Type of pain: Constant (Checkbox ON)
Pain Scale: 7
Note: Patient has requested analgesia
LOOK The details are added as a row in the Pain Assessment details list.
DO Close the Pain Assessment accordion by selecting the small black arrow on the accordion.
The default Status of this questionnaire is 'Entered'.

The status will affect the ability of changes being made to the document.
STATUS OUTCOME

Entered The additions and changes can be made to the form, it is not considered a final document
Authorised The form is considered final and additions and changes can only be made if they are
recorded as corrections. Security settings are available to limit who can correct an
authorised document.
Corrected The document has been changed by an addition or an existing entry was modified. A
Reason for Correction must be recorded and a flag will display next to the chart entry to
indicate that a correction has been made to an Authorised document.
DO Select the Update button to save the details and close the Wound Management screen.
LOOK The Wound Management edit screen closes, and the details are now visible in the Wound
Management Documentation profile of the ICU Care Assessments chart. The Wound
Management chart tab has a blue line next to it indicating that there is an entry in this profile.
DO Return to the Flowsheet by selecting the Back to: Flowsheet breadcrumb link.
LOOK The ICU Flowsheet displays.
DO The Registered Nurse documents the administration of an IV antibiotic via the flowsheet.
From the profile tabs above the ICU Flowsheet timeline, select the ICU Medications tab.
LOOK The ordered medications display in the medication profile. There is a hyperlinked
administration time displaying against the Metronidazole entry to show that it is due for
administration.
DO Select the link for the Metronidazole administration time.
LOOK The Intravenous Infusion administration screen displays.
A unique batch identifier is also associated with the administration to document the exact
preparation batch and expiration date of the drug that the patient is receiving.
DO The Registered Nurse completes the administration details

Initial Volume: 100 ml
Order Execution Started By:ICU1RN
Infusion Administration Set: 20 drops / ml
Alternate Location: Intensive Care W1
Batch No. (Select from lookup)
Password: demo
Select the Update to document the start of the infusion.
LOOK The Infusion Administration screen closes and the Medication Profile is displaying an
administration status of 'Started', and a blue administration line displays with an edit icon.

DO The Registered Nurse documents the Fluid Balance for the patient
From the profile tabs above the ICU Flowsheet timeline, select the ICU Fluid Balance tab.
Recording the fluid balance is a frequent and essential task for those looking after patients in
the ICU. All fluid inputs, (e.g. oral drinks, IV fluids, liquid feeds, bladder irrigation) are recorded
as a positive value and matched against all fluid outputs (e.g. urine, drains, aspirate etc) which
are recorded as a negative value.
As the day progresses the patient should be near a 'zero' balance - i.e. What goes into the
patient, will need to come out. If the balance is too positive it might be an early indicator of
organ failure or 'fluid overload' which can lead to serious cardiac complications. If the balance
is negative, then the patient may be in the early stages of a metabolic crisis or dehydrated,
again, if this is not recognised and treated in time, it could have fatal consequences.
LOOK The Flowsheet display changes to display a Fluid Balance chart, over an Inputs, Outputs and
Overall Fluid Balance Observation item grid. The Graph displays 2 Y axis - and a grey
background indicating 'below zero' (negative balance) and a white background indicating
'above zero' (positive balance).
DO The Registered Nurse realises that Thomas had a drink of 250 ml of water an hour ago.
Place the mouse cursor on the timeline one hour in the past and select it.
LOOK The time indicator line now displays over the selected time, and the time band column is
highlighted.
DO Select the Oral Intake input cell in the selected time column on the grid.
LOOK An Oral Intake input screen opens with the time of the selected time band column defaulted.
DO Record the Oral Intake

Value: 250
Comment:Reported by patient
Type: Water
Select the Update & Validate button to save the value.
LOOK The value is reflected on the timeline as a green block and a small + symbol that appears
above the 'zero' level indicating a positive total. Placing the cursor over the indicator will
display the total in a tooltip.
DO The patient requested a urine receptacle from the Registered Nurse an hour ago. The
Registered Nurse measures the volume of the urine as 400mls.
Record the Urine Output.
In the same time band column as the Oral Intake, select the Urine Output cell and record the
output.
Value: 400
Comment:Measured
Select the Update & Validate button to save the value.

LOOK The value is reflected on the timeline as a blue block and the small + symbol appears below
the zero level indicating a negative total.
DO The Registered Nurse documents the rest of the fluid for this hour
Select the time band corresponding with the current time
Thomas has a Softdrink of 350 mls and urinates 200 mls. The Registered Nurse also records
that Thomas received a 20ml IV Flush.
Record the Oral Intake for this hour

Value: 350
Comment:Reported by patient
Type: Soft drink
Select Update & Validate
Record the IV Flush for this hour

Value: 20
Select Update & Validate
Record the Urine Output for this hour

Value: 200
Comment:Measured
Select Update & Validate.
LOOK The graph now displays the new inputs and outputs and the Total Fluid indicator displays the
total fluid balance.
DO The Registered Nurse notes that the IV line pump was unplugged and the battery had died.
This is considered a clinical event as it impacted on the patient care, and needs to be
documented.
As it was noted quickly, and there was no harm done to the patient, the Registered Nurse
records this event with a 'moderate' severity level.
From the Action buttons select the Clinical Event button.
LOOK The Clinical Event edit screen opens.

The Date and Time corresponding with the time indicator on the timeline default.
DO Record the Clinical Event details.

Type: Equipment Malfunction
Severity:Moderate
Notes: Battery on IV 4000 pump depleted - device not plugged in overnight. Replaced.
Location:Intensive Care W1
Select the Update button to save and close the Clinical Event screen.
LOOK A green circle indicator displays on the timeline corresponding with the time of the Clinical
Event. Hovering the mouse over the indicator will display the summary of the event in a tooltip.
Selecting the indicator on the timeline will open the full details in an info pane.

DO The Intensive Care Registered Nurse uses the Logout link to log off from the environment.

1.9. Exercise – Inpatient Encounter Record
Learning Objectives
 View laboratory results
 Document Transfer Plan
 Document Estimated Date and Time of Discharge on Episode Details
 Associate problems with Encounter Record entries
 Search Encounter Record entries
Scenario
The Care Provider Dr Bill Paladino views the Clinical Priority Workbench and reviews Thomas
Connor's progress.
Thomas has responded well to treatment and can be discharged to the care of regular inpatient
ward. Dr Paladino prepares a Transfer Summary to communicate the ongoing care for Thomas.
Login Role: ICU1DR - Dr Bill Paladino, Intensive Care Specialist
DO The Priority Workbench displays.

The doctor selects a list of current patients.
Select the My Current Patients tab.
LOOK A list of all the patients currently under the care of the doctor displays. If required, the list can
be filtered by using the Additional Search Criteria contained in the accordion below the default
list filters. This will apply a filter to the list based on Ward, Specialty, Temporary Location,
Patient Surname, Results status etc.
DO Select the patient Action Menu icon from the end of the patient details row.
Select the Encounter Record menu from the action menu.
LOOK The Patient Summary chart displays as there are no Encoutner Record entries for this patient
by Dr Paladino. Dr Paladino can review the care details provided by the ICU nurse and the
emergency clinicians.
DO Select the New tab to create a new Encounter Record entry.
Create a New Encounter Entry

Select the + icon next to Doctor Assessment entry type
LOOK A list of available entry item actions display on the left pane for the Doctor Assessment Entry
Type selected.
DO Commence a new Planning Note.

Select the Add Planning Note action link.
LOOK The Clinical Notes edit screen displays.

DO Commence a new Transfer Summary report

Type: Planning Note
Note: (use canned text: \train2<space>)
Patient continues to respond well to treatment and is

exhibiting a reduced fever and lower pain levels. Discussed
treatment plan with Orthopeadic on call registrar who has
agreed to admit patient under their care for continued
observation, antibiotic treatment and preparation to go home.
Transfer patient to inpatient ward as soon as a bed can be
arranged.
Status: Authorised
Password: demo
Select Update to save the note and close the note editor.
LOOK The Clinical notes entry display in the Encounter Record.
DO Document the planned discharge of the patient within the Encounter Record.
Extra Actions: Add Medical Discharge
LOOK The Discharge Episode screen displays with the Estimated Discharge Date and Time fields
active
DO Enter in the estimated discharge date and time

Estimated Discharge Date: t (Today)
Estimated Discharge Time: 1800
Estimated Discharge Date Confirmed: checkbox ON
Select Update
LOOK An entry appears in the Encounter Record with the estimated discharge details.
DO Associate the current entry with the patients' problem of septic wound.
On the display row containing the Clinical Note details
Select the Action Menu icon.
LOOK The Action Menu for this entry displays
DO Select the Link Problems to Entry Item menu option
LOOK A list of active and inactive problems displays
DO Select the Link/Unlink Problem to Entry icon against the Septic Wound problem
Select the Back to: Encounter Record bread crumb link.
LOOK The details of the problem display against the note entry in the Encounter Record.

DO Review all clinical notes related to this problem.

In the Encounter Record tools
Select the Search tool icon.
LOOK The Search Screen displays
DO Expand the Search Options accordion
Keywords: Ankle Fracture
Select the Across Encounters checkbox ON
FIND.
LOOK Only those entries that are directly linked, or contain an item that is linked to the keywords are
shown. This can be useful to filter the notes viewed if the patient has had an extended stay, or
many different problems.
DO Save the Search criteria
Select the Save This Search button
LOOK The Save Search edit screen displays - the search criteria displays in a section called 'Data'.
The Access Type allows the search criteria to be saved at user, location or site level.
DO Enter details about the Saved Search
Description: Ankle Fracture Entries
Access Type: User
Default: (Checked on by default)
Update
LOOK The new Saved Searches entry is added to the Saved Searches list under the Encounter
Record Search Options. Next time a user wants to apply this search criteria, they Search
description link is selected.
DO Use the Logout link to log off.

1.10. Exercise – Inpatient Ward Transfer
Learning Objectives
 Transfer Patient to a new Care Provider and Specialty
 Ward Transfer via Inpatient Floorplan Links
Scenario
The ICU Ward clerk has received instructions from the Registered Nurse that Thomas Connor is
to be transferred into the care of the Orthopaedic team and prepared for a discharge later in the
day.
Login Role: ICU1CK - Ms Harriet Brown, Intensive Care Ward Clerk
DO Select the Action Menu icon on the row containing the patient in the list of Patients in Ward.
LOOK The Action Menu displays. Verify that the patients name displays above the Action Menu to
confirm the correct patient was selected.
DO The ICU Clerk checks the settings that indicate that the patient is expected to be discharged
later in the day.
Select the Medical Discharge menu from the action menu list.
LOOK The Discharge Episode screen displays. This screen can be used to plan for the patients
discharge, finalise their bill, capture the time of death, and document the actual date and time
of discharge.
The Estimated Discharge details entered by the doctor display as 'display only' text.
Note: The Total Bed Days and Length of Stay (LOS) are system calculated and displayed on
screen as read only.
It is important to NOT complete the Discharge Date or Time fields at this stage. If these are
selected the discharge will be finalised instead of being a 'planned' discharge.
Discharge Date and Discharge Time are the triggers in TrakCare to discharge an episode.
DO Without making any changes to the screen…
Select the breadcrumb link Back To: Ward List
LOOK The patient list displays.
DO The ICU Clerk now arranges the patient to be transferred to the Care of the Orthopaedic team.
Select the Action Menu icon for the patient in the list
Select the Movements menu from the action menu list.
LOOK The Unit and Care Provider Transfers screen displays. This screen contains three lists.

List Function
Unit and Care Document the transfer of care from one care provider to another, and from one
Provider - specialty to another.
Transfer List This list may also be used to document when a Care Provider provides a consultation
without becoming the main care provider for the patient.
The patient's physical movement within the hospital does not get recorded on this
list.
Bed Request List Document the physical movements of the patient within the hospital.
Captures temporary locations as well as bed and ward movements.
Leave List If a patient is still under the active care of the hospital, but needs to leave for either
therapeutic or personal reasons, they may be added to the 'Leave List' - this is to
record the temporary departure of the patient from the hospital without discharging
their episode.
Most frequently used in Physical Rehabilitation and Mental Health.
DO Record the transfer of the patients' care from the ICU specialty to the Orthopaedic specialty
team.
In the Unit and Care Provider -Transfers List, select the New button.
LOOK The Transaction Details screen displays - showing the current physical location of the patient.
The Transaction Start Date and Start Time have defaulted the current date and time.
DO The ICU Clerk enters the details of the transfer.

Department: Orthopaedics
Care Provider: Dr Abraham Altona
Main Care Provider: Checkbox ON.
Select Update to record the changes and transfer the patient to the care of the Orthopaedic
team.
Outlier:
An alert may appear at this time advising that the patient is an 'outlier'.
Outliers are patients who belong to a specialty that does not routinely get treated in a certain
ward. For example - Thomas has been transferred to the Orthopaedics specialty, but he still in
the Intensive Care ward. Orthopaedics patients are generally treated in the Orthopaedics
ward, but occasionally they may need to be admitted into other wards. In this care they are
identified as outliers, because they are 'outside' the typical type of patient treated in that ward.
Identifying outliers assists administrative and nursing staff to ensure that appropriate reporting
is captured, and the correct nursing skills and resources are available. There are some
security settings that will prevent certain groups of users from allocating outlier patients to
wards - in this scenario those settings are disabled.
LOOK A message displays a warning that the patient will be an 'outlier'
DO Select Confirm on the Outlier warning message.

Select the Home link to leave the Movement screen and display the home screen.

LOOK The Ward List displays. The patient is still listed in the ICU ward, and now has an expected
discharge date of today. Note: there is a blue indicator next to the patients' Unique Registration
Number (URN) indicating he is now considered an outlier as he is now under the care of the
Orthopaedics specialty while still admitted to Intensive Care W1. The name of the new Care
Provider is also displayed on the list.
DO The ICU Clerk has been informed by the Bed Manager the Orthopaedic ward is ready to
receive the patient on that ward.
Select the Floorplan icon to view the ICU Floorplan
Select the Toggle Linked Locations icon to view the linked locations
LOOK The linked locations list displays down the left side of the floorplan
DO Select the patient from the Floorplan by selecting any part of the bed space occupied by the
patient
Select the Nursing Station link for the Orthopaedic W1 ward from the list of linked locations
at the side of the floorplan.
LOOK The Transaction Details screen opens. The Orthopaedic W1 ward details, Nursing Station
room, Transaction Start Date and Transaction Start Time have defaulted into the relevant
fields.
DO Select Update to save the changes and record that the patient has been moved to the
Orthopaedic ward.
LOOK The floorplan displays. The patient no longer appears on the floorplan in the ICU. The bed he
was assigned to is displaying as closed for 'Cleaning'. Selecting the Orthopaedic W1 link will
display the floorplan for that ward, and shows that the patient is in the Nursing Station for that
ward.
DO The ICU Clerk uses the Logout link to log off from the application.

1.11. Exercise – Inpatient Ward Management
Learning Objectives
 Perform a Bed Swap between two patients
 View patient movement history
 Create a Follow up appointment by Ward Clerk
Scenario
Thomas Connor has arrived on the Orthopaedic ward. The Ward Clerk moves him into a bed in a
room on the ward. However, the Registered Nurse wants to move Thomas closer to the Nurses
Station so that he can continue to be monitored closely. The beds closest to the Nurses station
are currently occupied, so the Ward Clerk arranges a 'Bed Swap' between the patients.
The Clerk then reviews the movement history for Thomas to take note of the different specialties
he has been admitted under during this hospital stay, and to try to identify where his paper
record may be located.
Finally, the Clerk notes that Thomas needs a follow up appointment before he can be discharged
home and arranges this for early next week.
Login Role: ORT1CK - Ms Rebecca Sanderson, Inpatient Ward Clerk
DO Select the Floorplan View icon.

From the Nursing Station select the patient.
Select an available bed in Room 2.
LOOK The Transaction Details screen displays. The selected bed details, current date and time have
defaulted into the relevant fields.
DO The Clerk checks that the paper medical record has been transferred with the patient
Move All Records with Patient: Checkbox ON
Select Update to save and confirm the movement transaction.
LOOK The patient now displays in the selected bed. Moving the medical records on the transaction
will update the Medical Record location list to enable other users to locate the physical medical
record.
DO The Ward Clerk is advised by the Registered Nurse that he should be in a bed closest to the
nurses station for monitoring - This bed is Room 4, Bed 15, but it is occupied already by a
patient.
Select the patient details on the Floorplan
Select the Bed Number link on the occupied bed Room 4 - Bed 15.
LOOK The Bed Swap screen displays with the selected bed details.
DO Select Update to confirm and complete the transaction.

LOOK Both patients have swapped beds.
DO The Ward Clerk wants to review the Movements history for the patient.
Select the Action Menu icon for the patient from the floorplan.
Select the Movements menu from the action menu list.
LOOK All the Movement transactions for this inpatient episode are displayed.
DO The Clerk has been asked to create a follow up appointment in the clinic with the Orthopaedic
team next week.
Select the Action Menu icon from the patient menu.
Select the Multiple Appt action menu from the list.
LOOK The Episode List for the patient displays. The current inpatient details display.
DO The Clerk wants to create a new Outpatient Episode for the Orthopaedic clinic visits.
Select the New button.
LOOK The Episode Registration edit screen displays
DO Complete the Outpatient Registration details

Location (Specialty): Orthopaedics
Care Provider: Dr Abraham Altona
Select Update to save the details and create the outpatient episode.
LOOK The Appointment Search screen displays. The Specialty Location and the Resource details
have defaulted through from the episode details.
DO Select the type of appointment to search by:

Service: New visit
Expand the Day / Time accordion
Date: 1w<tab> (one week from today)
Select the Find button to search for available appointment slots.
LOOK The Available appointment slots for next week display in an appointment list. Each row
represents an available appointment time slot.
DO Select an appointment time checkbox.
LOOK The appointment details populate in the List of Services / Clinics on the Appointment Search
screen
DO Select Update to save the appointment details and return to the home screen.

LOOK The Home screen displays - The Administrative Info Icon Group is displaying an indicator that
new information is available.
DO The Ward Clerk uses the Logout link to log off from the application.

1.12. Exercise – Inpatient Discharge Planning
Learning Objectives
 Ordering Discharge Medications
Scenario
Thomas has improved and is now ready to be discharged home. The Doctor performs a final
assessment and orders medications for Thomas to continue taking when he is at home.
Login Role: ORT1DR - Dr Abraham Altona, Orthopaedic Consultant; Logon Location: Orthopaedics
LOOK The Priority Workbench diary displays for the logged in Care Provider.
DO From the top of the Clinicians Priority workbench

Select My Current Patients tab.
LOOK A list of Dr Abraham Altona's patients displays.
DO Select the patient's Action Menu icon from the patient list.
Select the Encounter Record action menu from the list.
LOOK The Encounter Record entry screen displays.
DO Create a new Discharge Note entry.

Select the New tab
Select the + icon against the required entry type: Discharge Note.
LOOK The new entry displays with the discharge note Actions.
DO Review current medications and create an order for discharge medications for the patient to
take after they go home.
Select the Add Order Action link.
LOOK The Order Entry screen displays.
DO View a list of current active orders
Select the open book icon (Current Medications Chart)
LOOK The Current Meds chart displays on the right hand side of the screen.
DO Activate the selection checkboxes
In the Current Meds chart header, select the Toggle Multiple Selection Checkbox icon to

activate the selection checkboxes.
LOOK The items in the list display with a selection checkbox next to each item
DO Select the checkbox against each of the medication order item/s to be discontinued
Select the Current Meds chart Options Menu icon (vertical ellipsis)
LOOK A list of options displays for the Current Meds chart
DO Select the Discontinue option
LOOK The Discontinue Order screen displays
DO Complete the required information
Variance Reason: Completed Order / Therapy
Password: demo
Update
LOOK The Order Entry screen displays, and the Current Meds chart no longer displays the
discontinued medications.
DO The Doctor decides to order Amoxicillin 500mg to be taken orally 3 times a day and a
combination codeine 60mg and paracetamol 1gm analgesic to be taken orally for pain as
required (PRN) as discharge medications.
In the order item lookup

Item: Amox 500 cap
Select Amoxicillin 500mg capsules
Use the Cart icon to see the item in the Order Cart
LOOK The Order Details display, however there is an red Alert indicator displaying.
DO The Doctor reviews the Alert details.

Select the Alert Details icon in the Order Entry Toolbar.
LOOK The Messages and Alerts chart displays. Details about the order and the type of alert display.
DO After taking note of the alert, the Doctor decides not to continue with the order as the risk of an
allergic reaction is too high.

Within the Messages and Alerts chart

Select the checkbox next to the Order line for the item to be canceled.
Select Cancel Items link in the button bar.
LOOK The Alert Details screen closes. All items in the alert details that were selected have been
removed from the Ordering cart.
DO The doctor orders an alternative antibiotic drug: clarithromycin 250mg BD x 5 days

Item: clari 250 tab
Select Clarithromycin 250mg tablets from the lookup results.
LOOK The Order is added to the cart - a grey indicator denotes that the order details are incomplete.
DO Select the details of the medication in the chart
LOOK The Medication Order Details screen displays. The priority defaults to Normal - however these
medications are to be dispensed when the patient is discharged, and not while the patient is
still in hospital - therefore this priority will need to be changed to 'Discharge Meds'.
DO The Doctor prescribes the Clarithromycin 250mg tablets to be taken twice a day for 5 days as
a discharge medication.
In the Order Details screen.
Priority: Discharge Meds
Dose: 250 mg
Frequency: Twice Daily
Duration: For 5 Day(s)
Select Update to save the changes to the item in the pending orders list.
LOOK The prescribed medication is visible in the ordering cart list.
DO The Doctor prescribes the analgesic

Select the Favourite Orders icon (star symbol) from the Order Entry Tool Bar
Select the Medications favourite orders list
Select the Others list
Select Paracetamol + Codeine 500mg+30mg order favourite from the list.
LOOK The order is added to the Order Entry Cart. The Doctor will need to adjust the details to ensure
this prescription is suitable for the patients discharge.
DO The Doctor prescribes Co-Codamol (Codeine and Paracetamol) 60mg+1g to be taken orally
PRN for pain every 4 hours, not exceeding 8 tablets every 24 hours as a discharge medication
for 3 days.
Select the Codeine and Paracetamol order item in the Order Entry Cart.

LOOK The Medication Order Details screen displays
DO Change the order details.
Priority: Discharge Meds

Dose: 2 tablet(s)
Frequency:Every 4 Hour(s)
PRN: Checkbox ON
Maximum QTY in: 8 tablet(s) - every 24 hours.
PRN Indication: For pain and inflammation of ankle
Duration Options: For 3 Day(s)
Select Update to save the details and display them in the orders cart list.
LOOK A Red Alert Indicator displays next to the order item in the Order Entry Cart list. Therapeutic
Duplication displays for the co-codamol - this is because the patient has an active order for this
medication with a priority of 'Normal'. As these orders have a priority of 'Discharge
Medications' they will not be administered by the inpatient care team.
DO
Select the Alerts icon in the Order Entry Tool Bar to review the alert details.
LOOK The Messages and Alerts details display.
DO Select the Checkbox on the order line for the item to be ordered
Select Reason for Override: Alert noted and order required

Select Update Alerts to document the Reason for Override
LOOK The Alerts clear and the Pending Orders list can now be ordered.
DO The doctor saves the pending orders and reviews the order summary screen
Password: demo
Select Update on the Pending Orders list to save the pending orders.
LOOK The Medication Orders display in the Plan section of the Encounter Record.
DO The Doctor will now enter an Estimated Discharge for the patient for this episode.
Use the Back To: breadcrumb links to return to the Encounter Record open entry.
Select the Add Estimated Discharge action link.
LOOK The Discharge screen displays. At this stage the fields Med Discharge Date, Med Discharge
Time and Medically Fit check box are disabled.
DO The Doctor enters:

Estimated Discharge Date: Today

Estimated Discharge Time: n-5

Estimated Discharge Confirmed: Checkbox On
Select the Update button to save the changes.
LOOK The middle frame of the Encounter Record displays: 'Expected to discharge on dd/mm/yy,
time confirmed' .
DO The Doctor will next prepare to Medically Discharge the patient for this episode.
Select the Add Medical Discharge action link.
LOOK The Discharge screen displays. The fields Estimated Discharge Date, Estimated Discharge
Time will default with values previously entered and the Medically Fit check box is
ticked/selected. All fields are greyed out.
DO Document the medical discharge details:

Med Discharge Date: Today
Med Discharge Time: Now
Medically Fit: Checkbox On
Medical Discharge Doctor: Dr Abraham Altona
Primary Diagnosis: Severe sepsis with septic shock
Select the Update button to save the changes.
LOOK The Encounter Record screen refreshes and the Medical discharge details are visible in the
middle frame showing 'Patient is Medically Fit'.
DO The Doctor closes the Discharge Note entry in the Encounter Record entry by selecting the
padlock icon on the Discharge Note entry's accordion.
LOOK A confirmation displays - Selecting OK will close the entry and the Patient Clinical Summary
chart displays in an info pane.
DO The Doctor selects the Logout link to log off from the application.

1.13. Exercise - Inpatient Discharge
Learning Objectives
 Discharge patient from Inpatient Unit
Scenario
The Clerk prepares Thomas for discharge, and documents when he leaves the care of the
Inpatient ward. This will mark the end of the Inpatient episode for Thomas.
Login Role: ORT1CK - Rebecca Sanderson, Ward Clerk
DO The Clerk prepares to discharge the patient from the ward.

Select the Action Menu icon for the patient from the patient list.
Select the Discharge Final / Financial menu.
LOOK The Discharge Episode screen displays. The details previously entered for both the Estimated
Discharge and Medical Discharge have defaulted through.
DO The Clerk documents the final discharge

Discharge Date: t (for today)
Discharge Time: n (for now)
Separation Type: Medical Discharge
Discharge Destination:Home
Discharge Condition: Medically fit
Select the Update button to complete the final discharge and close the screen.
LOOK The screen closes and the patient is no longer showing on the patient list. The Status of Beds
list is displaying an Unavailable Reason of Cleaning against the bed the patient was
occupying.
DO Change the status of the bed to Available
Select the Action Menu icon against the row that is displaying the Status of Beds
Select the Bed menu option.
LOOK The Bed Status Change scree displays with a list. In the list the details of the current
Unavailable Reason are displaying.
DO Select the Start Date hyperlink to edit the details of the current status.
LOOK The details are added to the Bed Status Change edit fields -
DO Change the End Time
End Time: Now

Update
LOOK The Status of Beds list displays, and the bed is no longer displaying an Unavailable Reason -
It is ready for the next patient.
DO The Clerk selects the Logout link to log off from the application.

InterSystems Corporation
World Headquarters
One Memorial Drive

Cambridge, MA 02142-1356
Tel: +1.617.621.0600
InterSystems.com
Refer to help instructions for safe use
InterSystems TrakCare, InterSystems HealthShare, InterSystems IRIS Data Platform, InterSystems Caché, InterSystems
Ensemble, and InterSystems DeepSee are registered trademarks of InterSystems Corporation. Other product names are
trademarks of their respective vendors. Copyright © 2019 InterSystems Corporation. All rights reserved. 5-19

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TRAINING

TrakCare Fundamentals Day Two

Title: TrakCare Fundamentals Day Two Medical Patient Journey

Description: This document is a Training Exercises booklet for a Learning Services

Copyright © 2021 InterSystems Corporation. All rights reserved.

TrakCare Fundamentals Day Two Medical Patient Journey v5.03

1. Day Two Medical Patient Journey ............................................................................................... 2

TrakCare Fundamentals Day Two Medical Patient Journey v5.03

Version Date Description of Change Modified By

v0.1 01/06/20 Adapted to MEUI S.Evans

v5.02 29/10/20 ACN to Encounter Record S.Evans

v5.03 19/01/21 Update to MR5 SE and BA

TrakCare Fundamentals Day Two Medical Patient Journey v5.03

1.1. Exercise - Emergency Patient Admission

Login Role: EMD1CK - Sandra Paterson Emergency Department Clerk

Content / Key Points / Instructions

Select the Main Menu icon

LOOK The Patient Search screen displays.

DO Search for patient details

TrakCare Fundamentals Day Two Medical Patient Journey v5.03

DO The Clerk enters the expected arrival details:

Expand the Seen accordion.

Expand the Episode Details accordion.

DO Select 'Ok' on this message:

DO The ED Clerk selects the Logout link to log off.

TrakCare Fundamentals Day Two Medical Patient Journey v5.03

Login Role: EMD1RN - Mr Xavier Jung Emergency Registered Nurse

Content / Key Points / Instructions

Scale Number Category Description Time to be seen

1 Immediate resuscitation Immediate

2 Very urgent up to 10 minutes

5 Non Urgent up to 120 minutes +

DO The Triage Nurse documents the Triage Assessment findings:

TrakCare Fundamentals Day Two Medical Patient Journey v5.03

DO Document the Triage Symptom details

LOOK A list of common problems displays.

DO Select the problem description:Rapid Onset

DO View the problem Adult > 16 yrs (> 38.5C) unwell

DO The nurse continues to document the triage details:

The nurse documents the Observations:

TrakCare Fundamentals Day Two Medical Patient Journey v5.03

DO Reason for Override: Known condition Alert noted

LOOK You are returned to the start/home page.

DO The Triage Nurse assigns Thomas to an available bed.

TrakCare Fundamentals Day Two Medical Patient Journey v5.03

Login Role: EMD1DR - Dr Terry Murphy Emergency Doctor

Content / Key Points / Instructions

DO Dr Murphy takes on the care of Thomas Connor.

Emergency Consultant: Dr Ed Quigley

Likely To Admit: Yes

DO Dr Murphy now reviews Thomas' record

TrakCare Fundamentals Day Two Medical Patient Journey v5.03

View the Patient's History section

Review the Active Problems

Scroll down to the Observations section

View Vital Signs (Last Entry) chart.

LOOK The observations recorded by the nurse during Triage display.

DO Select the EPR Chartbook icon.

LOOK The EPR chartbook displays

DO View Doctors Assessment chart

LOOK Notes display from previous episodes.

DO Dr Murphy documents the patient problems in the Encounter Record.

DO Dr Murphy documents the Reason for Encounter.