Student RN-Overview of Flowsheets
and Documention Lesson Plan
Agenda................................................................................................................................... 1
Reviewing Notes .................................................................................................................... 2
Doc Flowsheets ...................................................................................................................... 2
Documenting the Patient Profile ....................................................................................... 12
Documenting Basic Intake and Output ........................................................................... 13
Documenting I/O at the Correct Time ............................................................................. 13
Agenda
The following is a breakdown of time for each major part of the lesson.
Time (min)
Topics
5
Notes Activity
30
Doc Flowsheets
10
Documenting Basic Intake/Output
45
TOTAL TIME
2
Reviewing Notes
QSG – Page 15
Ellie is a post appendectomy patient
Open Ellie’s chart
Click on the Notes Activity
These notes are from Ellie’s current admission
They are listed in chronological order with the most recent note at the top
Sort the notes by clicking on the different column headers like Author
Name or Type
Filter the notes by using the tabs across the top of the Notes activity
(Click on the Consults and Periop tabs)
What questions do you have?
Doc Flowsheets
QSGs-pages 16-21
Click the Doc Flowsheets activity
The Vital Signs flowsheet is the default flowsheet
Notice the tabs across the top
To navigate from flowsheet to flowsheet, click on the appropriate tab
Let’s review some EPIC terminology regarding Doc Flowsheets (Instructorpoint out the below bullet points)
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Doc Flowsheets have a table of contents on the left side
The ―Groups‖ are listed in the table of contents
Within the flowsheet, the ―groups‖ are bolded in black
Underneath the group name are the rows in which documentation is
charted/filed
Click on Height and Weight in the table of contents
By clicking on the Group name, the system will ―jump‖ you to that group
In Doc Flowsheets, you need to add the correct time column (Instructordemonstrate and have class participate)
The buttons are located on the toolbar
Add Column: Click the Add Column button to add a column for the
current time
Insert Column: Click the Insert Column to add a column for an earlier
time (can use the shortcut n-10 or type in the time)
Important point: The columns we just added do not cross over to the other
flowsheets
Click on the Patient Care Summary flowsheet tab
Do you see the time columns you just added to the Vital Signs flowsheet?
(no)
The Patient Care Summary is a condensed flowsheet
Click on the Pain group in the table of contents to expand this group
Doc Flowsheets are used by many clinicians. To review previous documentation
by other clinicians:
Use the scroll bar on the bottom of the screen
To look at a specific date, use the ―Go to Date‖ button on the toolbar
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Documenting Patient Information
There are two ways to document:
Documenting in the rows
Documenting using the Details Window located on the right side of your
screen
Click on the Vital Signs Flowsheet
First we will document in the flowsheet rows
We just took Ellie’s vital signs, what button do we click first? (Add Col)
(Instructor – encourage class participation)
Complete:
Temp
Temp Source
Heart Rate
Heart Rate Source
Respirations
Blood Pressure (see the tips for BP on page 17 - enter with a slash or a
space )
Location/Method/Patient Position
SPO2
Click on Height and Weight in the table of contents
See the Tips for entering Height and Weight in your QSG-page 17
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Height: 5f7i
Weight: 130lb (Instructors- you need to enter this weight)
What happened when you entered in a height and a weight for Ellie?
Her BSA and BMI are automatically calculated.
Filing Flowsheet Data
Notice your data is pink
This indicates that the data is pending – it hasn’t been filed permanently to
the patient’s chart
Click File (located on the left side of the toolbar)
The data turns black and becomes a permanent part of the patient’s record
In addition, if you log out of Hyperspace or navigate to another part of the
patient’s chart and do not click the File button, the system will file and save
the information for you
Correcting Data Entered in Error
You can correct data entered in error by entering the correct data,
entering a comment, and clicking File
Go back to the Weight row
Click in this row, delete the information, and enter 125lb
In the Weight row, click the white paper icon and enter the comment:
Entered 130lb in error
Click Accept
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Notice the piece of paper now has blue lines indicating a comment has been
entered
―Hover to Discover‖ over the paper icon to view the comment
Click File
A red triangle appears for Edited data
Use the Legend button to see what the different icons represent
Since the documentation is part of the patient’s permanent record, the
system creates an audit trail
Click in the row of the value you just edited (Weight)
On the bottom of the Details Window/Report, find the Show Audit box
Click the double arrows to open and see your edited values and comment
Correcting Data Entered On The Wrong Patient
If you have entered flowsheet data under the wrong patient
First, you must manually delete all of the data in each row and enter a
comment
Then, you will need to chart on the correct patient
You cannot Copy and Paste
My suggestion to you is to keep only one chart open at a time (you can
have two charts open at one time)
What questions do you have?
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Documenting A Shift Assessment
Click on the Patient Care Summary flowsheet tab
The Patient Care Summary flowsheet is used to document your clinical
assessment
The Patient Care Summary is organized around Functional Health
Patterns which focus on Within Defined Limits (WDL) and Exceptions,
Additional Documentation, and Interventions
There are a number of PCS flowsheets in the system that are patient
population-focused (e.g OB, ICU)
Scenario: We just completed a head-to-toe assessment of Ellie.
What Button do we click on first?
(Add Column)
Let’s practice documenting using the Details Window located on the right side of
your screen
The Details Report helps you quickly identify and select the choices for a
given row
It also has important row information and gives you a WDL definition for
some groups
You can also quickly advance to the next row
Use the black arrow to navigate through the Details Window
Notice the ―Select Single Option‖
Charting Type: Shift Assessment
We will skip Significant Event; click the black down arrow or press the
enter key
Cognitive/Percepual/Neuro WDL row, select WDL Except
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A cascading window appears for us to pick our exceptions
We do not want to pick all of the suggested rows
Highlight Level of Consciousness on the left side of the screen
Click the Add button
Level of Consciousness now appears on the right side
Another way to Add is to double click on that suggested row
Double click on Arousal Level
Double click on Orientation
Click Accept
These three rows are now added to the flowsheet; we can now chart by
exception
Level of Consciousness has ―Select Multiple Options‖
Select Sedated
Since this is a ―Select Multiple Options‖ row, you are NOT advanced to the
next row
You have to either right-click within the box or press Enter to advance to
the next row
Left-click to pick
Right-click to stick
Arousal Level: Arouses to voice
For Orientation: person and time (Ellie thinks she is at home)
Using your black down arrow in the Details Report/Window, navigate to the ―Is
Pain Present‖ row
Is pain present? Yes
A Cascade Window appears
Select the first Number Scale
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Notice that some of the rows are already added/grayed out
The PACU nurse just added the rows she needed
We want all of the rows added to the flowsheet
Click Add
Click OK
We add a Number Scale for each pain location (e.g. If Ellie has a headache
in addition to abdominal pain, we would add Number Scale 2)
Presence of pain: complains of pain/discomfort
Location Side: right
Location/orientation: lower
The locations are listed head to toe; there is a shortcut to use
In the Location box, type a ―A‖ and select Abdomen
If you know your choices, you can also use this shortcut in the rows
Skip the ―Pain Radiation To‖ row
Complete the Pain Rating at Rest and with Activity
Nonverbal Indicators of Pain: Select a few
You must complete the ―Comfort/Acceptable Pain Level‖ row (required
documentation)
I will give you a minute to complete the rest of the group using the Details
Window
You can chart either in the rows or in the Details Window
It is your charting preference
A little tip: Try not to use both; this will prevent the system from freezing
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Let’s document on a few more Groups.
Document using the rows or the Details Window; it is your choice
Navigate to the Respiratory WDL row.
Using the scenario on your tent card, document the following: (Instructor – class
participation)
Ellie has a frequent non-productive cough and both of her posterior lower
lobes are diminished. She does cough and take deep breaths on her own.
Select EX= WDL Except
Add Cough Frequency and Type
Do you see any row for breath sounds? (No-we will cover next)
Cough Frequency: Frequent
Cough Type: Non-productive
If you do not see exception rows under the first cascade window, use the
Additional Documentation row.
Additional Documentation: Yes
Click the plus sign in front of Breath Sounds
Add LLL and RLL posterior breath sounds only and click OK
Document Diminished in both rows
Under the Respiratory Interventions group:
Additional Documentation: Yes
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Add Cough and Deep Breathing
Done independently per patient
Navigate to the Gastrointestinal WDL row.
Her abdomen is distended. Her upper bowel sounds are both hypoactive.
Select EX= WDL Except
Add LUQ and RUQ Bowel Sounds (Abdominal appearance already added)
Abdominal Appearance: Distended
LUQ Bowel Sounds: Hypoactive
RUQ Bowel Sounds: Hypoactive
Click File
Cascade windows may not appear everytime information is documented.
This is to prevent ―pop up fatigue‖
You can manually bring up the cascade window by clicking on the icon
with the green arrow
Comments can be entered under any flowsheet row
Comments helps communicate information that might be considered noncritical yet valuable when assessing a patient
What questions do you have so far?
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Documenting the Patient Profile
The Patient Profile flowsheet contains patient/family provided information
(patient/family story)
It is started on admission and updated throughout a patient’s hospital stay
Click the Adult Patient Profile tab
We will record Ellie’s information in real-time
What is the first thing we need to do?
(Add Col)
In the General Information, document:
Temporary Family Living Arrangements: staying with family
Arrived From: emergency department
Under Mutuality/Role Relationships:
Significant relationships: sister
Primary Roles: wage earner
Limitations on Visitors: only immediate family may visit
Click on Patient Belongings Sent Home:
Make a few choices—notice that rows are automatically added from
your choices
Complete the specific items (e.g what type of jewelery, clothes, etc)
Valuables Sent Home With: Sister
File
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Documenting Basic Intake and Output
QSGs-Pages 22-23
Click the I&O flowsheet tab
Click Add Column
a. You check Ellie’s water cup and she drank 300 mL.
b. Click on the Intake Group in the table of contents.
c. Enter her intake amount under PO.
d. Ellie had a urine output of 350mL.
e. Click on the Output group in the table of contents.
f. Enter the output amount in the Urine row.
g. Ellie also told you that she had a small bowel movement an hour ago.
h. Click on the unmeasured output group in the table of contents.
i. Insert a column for an hour ago (h-1).
j. Enter 1 in the Stool Occurrence row.
I&O totals are automatically calculated in the Intake/Output activity.
Click the Intake/Output activity
This is a read-only activity
Documenting I/O at the Correct Time
Make sure you are documenting your intake and output BEFORE the end of
your shift.
Notice the shift times. (Instructor-point out the different shift times)
For charting purposes, the three shifts end at the 59th minute
This is especially important for I/O accuracy
What questions do you have about documenting basic I/O?
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We will learn how to document intake from IV fluids later in the training.
Some Additional Information:
The Shift Assessment activity is a nurse’s navigator
Navigators are designed to organize a specific user’s workflow
You can document some flowsheet information in the Navigator like vital
signs and risk assessments
If the flowsheet is too large, the system will automatically take you to Doc
Flowsheets
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