Transcript Paragon Training - Seton Medical Center Harker Heights

Paragon
Training
Nursing Students
Logging In
 At
Seton Medical Center we have Single Sign On
which allows you to swipe your badge for login.
 Swipe your badge over the reader
 The
Unlock Workstation Window
Opens; enter your password
And click OK
Logging In (cont)
 Double
Click on the Paragon Shortcut on the
computer’s Desktop
 The
Paragon Applications will open. Double click
on the Clinical Carestation
Clinical Care Station (CCS)


When you log into CCS the Splash Screen Opens. To access
your patients click on the
icon in the center of the
screen.
In CareGlance look to ensure you defaulted to the correct
Nursing Station. If not, click on the drop down arrow for the
Nursing Station and pick the correct Unit you are working
on.
CCS (cont)
Assigning your patients
Click in the “Assign” Box next to
your 1st “assigned” Patient
The “Self Assignment – Shift Selection” Box will open
1.
2.
3.
Choose your shift from the drop down arrow
Click the “Assign…” box so that when you click
the other patient’s assigned to you, you don’t
have to complete this box again
Then Click the OK button and finish assigning
the rest of your patients to yourself.
CCS (cont)
Assigning your patients


After assigning yourself your patients click the “Assigned
Patients” box (next to the Nursing Station Field.
Click the “Retrieve” Button
(think of this as your “refresh” button)
“Bubbles”

All patients have “bubbles” to the right of their names w/ initials
above them. Here are a few you will be ac
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AA – Admission Assessment (this one is done by the staff RN, but if it is GREEN then it is
clear that an Admission Assessment has been completed by an the staff RN)
FS – Flow Sheet
RX – Medication Administration
NR – New Results
Doc – Physician Progress Notes (if they do electronically)
There is a “legend” icon
located in the Secondary
Tool Bar that can be used
to assist you w/ what the
color scheme in the
bubbles indicate.
CCS (cont)
Patient Profile


The Patient Profile supplies information on patient’s Home
Medications, Allergies, Admission Height & Weight, etc.
To Access Highlight the patient you wish to view and click
the Patient Profile Icon in the Primary Tool Bar .
CCS (cont)
Patient Profile

To see the Admission Height & Weight (and some additional
information) Click on the down arrow in the Patient Banner

To close this screen simply click the up arrow at the bottom
of the screen
CCS (cont)
Patient Profile


Another important icon located in the Patient Profile is the Patient History
Single Click the icon for the Visit History Window to Open
When the Visit History window
opens Single click on a visit(at
the top of the screen)
To review diagnostic tests for
that visit on bottom half of
screen.
Double Click on a visit (at the
top of the screen)
To Open the Patient’s Medical
Record to view H&Ps, and
other documentation
Icon.
HPF (Horizon Patient Folder)
(The patient’s legal record)


When HPF Opens there is a one
time set-up that will have to be
completed before any
documentation can be seen.
Click: File  Preferences 
Personal Record View
Personal
Record View:
Click the Add
All button to
move all
“Documents
Not in View to
the right
“Documents in
View” then
Click OK
Exit HPF through the Door
Daily Assessments
 This
Assessment Type is where you
document your shift baseline head to toe
assessment, your hourly rounding (on the
Peep Tab), your pain assessments, IV
assessments, etc.
 Your instructor will let you know how often
she expects documentation in these
areas.
Daily Assessment (con’t.)

Click on the “Change Unit Type” Icon
Select the Unit Type of LHP-MedSurg
in the primary tool bar.

Click on the “Perform Assessment” Icon
“Daily” Assessment

The Daily Assessment will open to reveal these categories (Tabs)
and choose the
Daily Assessment (con’t.)
Components of the Daily Assessment
 The Assessment is made up of “Tabs” or
“Categories”.
 Within those Tabs are Group Boxes
 Within
the Group Boxes are Finding Codes
 Together these components make up your
documentation.
 A Head-to-Toe Assessment is completed on the
tabs that are all upper-case:
Daily Assessment (con’t.)
 In
the Daily Assessment you do have a way to add
extra information during your assessment. This can
be done 2 ways

1st Way: Create a “Group Note” which allows 255
characters. Simply right click in the group boxes
header and click on “Group note”

The blank Group Note Screen will open and you can
type up to 255 characters.
The little yellow piece of
paper will show in the
Group Notes Header
Daily Assessment (con’t.)
 In
the Daily Assessment you do have a way to add
extra information during your assessment. This can
be done 2 ways

2nd way: Create a “Category Note” which allows 255
characters. Simply right click anywhere in the Gray
portion of the screen click on “Category Note”

The blank Category Note Screen will open and you
can type up to 255 characters.
The little yellow
piece of paper
will show on the
Category Tab
Daily Assessment (con’t.)

System Assessments are all designed in the same format. All
“normal” findings are at the top of the page w/ all “abnormal”
findings below (see SKIN tab)
Normal
Abnormal
Daily Assessment (con’t.)
Hendrich II Fall Risk Model

SMCHH uses the Hendrich
II Fall Risk Model. This
model has 2 components
(Risk Factor & Get-up-andGo Test) that are added
together for a score. If the
score is equal to or greater
than 5 the patient is
considered High Risk for
Falls and Fall Precaution
Bundle is put in place.
Daily Assessment (con’t.)
McKesson Pain Assessment

SMCHH uses the McKesson Defined Pain
Assessment Screen. This is embedded
into the Daily Assessment

Click on the Pain Assessment button
Click on the New button at the bottom
of the window to open a “New” Pain
Assessment
Click within the fields for the drop down
choices.
If this is a pre-intervention assessment
click the pre-intervention assessment
option and be sure to re-evaluate your
patient after intervention. Upon re-eval,
click the post-intervention assessment
option.



Daily Assessment (con’t.)
 “Rounding”
at SMCHH is done on the
Peep and/or Intervention tabs
 You only document on the tabs that you
need.
 To close an assessment ALWAYS “yellow
arrow” out.
 You will be asked “do you wish to close
this assessment? Click YES if you have
completed the assessment of NO if you
wish to come back and finish the
assessment later
Follow-UP Assessment
Type = TEACHING

ALL Teaching documentation is completed under the
“Follow-Up” Assessment Type
Click on the “Perform Assessment” Icon

Select the Follow-Up Assessment

The Follow-Up Assessment will open. There are 3 tabs:

Follow-UP Assessment
Type = TEACHING
Admit/Assess Educ
Follow-UP Assessment
Type = TEACHING
Ongoing Education
Follow-UP Assessment
Type = TEACHING
Medication Education
Wound Assessment
Type




Assessments of Wounds are done in the Wound Assessment Type.
Click on the “Perform Assessment” Icon
Select the Wound Assessment
The Wound Management Window will open. If this wound has been
documented and this is the wound you are assessing simply double
click on that site. If it is a “NEW” wound, click on the scroll in the
secondary toolbar.
Wound Assessment
Type

If documenting on an existing wound when the assessment opens, the top
half reveals the baseline Wound Info (it is not editable). The Site Assessment is
on the lower half and reveals the last assessment completed. To start a new
site assessment click on the Insert button. To view assessments prior click on
the arrows at the bottom of the screen.

The new Site Assessment
will open to allow for
documentation. When
completed, click OK and
the assessment will close
Wound Assessment
Type


If documenting a “NEW” wound, click on the scroll in the secondary toolbar.
The top half of the screen “Wound Info” is the baseline wound information and
once saved this cannot be changed. The bottom half, “Site Assessment” is the
nurses assessment of that wound. Once completed click OK to close the
assessment.
Flow Sheet
 In
(Vital Signs, I/O’s, Measurements, and IV insertions)
the CareGlance screen double click on the FS
bubble
 When the Flow Sheet screen opens right click in
the “white” space to select what you need to do.
Flow Sheet (con’t.)
Vital Signs:
Enter your vital signs and then click “OK” at the bottom of the screen
Flow Sheet (con’t.)
I/O’s:
Enter your I/Os and then click “OK” at the bottom of the screen
Flow Sheet (con’t.)
IV Management
IV Site List Screen will open. Click on New IV Site and then OK
Flow Sheet (con’t.)
IV Management

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The IV Site Screen will open and the Started By Field will default to
you.
Click the drop down arrow to choose the IV Site
Click the drop down arrow to choose the IV Type
Enter Catheter size
Enter Site Started Date and Time
Areas in Bold must have entries
Flow Sheet (con’t.)
IV Management

Click the OK at the bottom of the screen

IV Entry: Do you want to save your changes? Click Yes
Flow Sheet (con’t.)
IV Management

The Fluid Screen will be available to add Fluids if you are hanging a
bag at the time of IV Insertion.
Enter Fluid Type (i.e. NS)
Fluid Started By defaults to the user
Enter Starting Volume
Enter Rate

Then Click OK and Save your changes.

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IV Management


Assessment of IV’s is in the Daily Assessment under the Intravenous
Tab
The IV Assessment looks like this. Click on the IV Site you are
assessing and complete the fields.
Order Management
Application



There are two tabs in Order Management (OM) that we will cover.
One is the “DIET” Tab and the other is the “Inquiry” Tab.
To access OM highlight your patient in Clinical CareStation (CCS).
Click on the OM Icon (aka “Pizza Hut”)  in the Primary Tool Bar.
This will open the OM Application and the Order Entry Tab is
defaulted.
Order Management
Application

Click on the Diet Order Tab to view your patient’s diet order.
Order Management
Application

Click on the Order Inquiry Tab to view ALL orders that have been
placed on your patient as well as see results. To view results, highlight
the order you wish to review and click the “Results” button to the right
of the screen.
Normal
Abnormal
(out of range)
Resulted
(no ranges)
Critical
Result
ADMINISTERING
MEDICATION(S)
Administering
Medication(s)
 The
Medication Administration
Application can be accessed two
different ways.
 The Most Common way is through the
Rx Bubble
on CareGlance Screen
 The other option is to click on the
Medication Administration Icon in the
Primary Tool Bar
Administering
Medication(s)
1
Identify your patient w/ two
identifiers – Once the MAR is
loaded – Scan your patients
armband.
Scan the
Medication(s) you
wish to administer to
the patient
2
Administering
Medication(s)
A Lock will appear on
the Admin. column.
Medication(s) are now
“PENDING”
Administering
Medication(s)
1
Click “Confirm” after reviewing that Total
Scan matches Ordered Dose (The example
here is different as patient only wanted 1 Tylenol).
Complete Administration Screen to
include any edit boxes that are required
(i.e. Early/Late Doses)
Go to “Pending” Folder to
verify that medication(s)
were scanned. Look for a
green checkmark to the left
of medication(s) scanned.
2
Administering
Medication(s)
Once you click “confirm” the
Administration Window will open
(5 rights, PRN Reasons, Late Dose Code, etc.)
Areas that must be completed
will be BOLD.
Administering
Medication(s)
You are Ready to Administer
Your Patient’s Medications
After Administering your Patient’s Medication
Click the CHART Button! If you don’t, the
medications will go back into the eMAR like they
were never given.