Documenting Vitals And Assessments Flashcards
What color are the values prior to filing them to a patient’s chart? What color are the values after they are filed?
Values are PINK prior to being filed.
Values are BLACK after they are filed.
List at least three pieces of information that can be found in the Details report within the Flowsheets activity
The value, comments, time taken, time recorded, user taken, user recorded and show audit
True or false? If a clinician closes a patient’s chart without clicking File in the Flowsheets activity, any unfixed data in the Flowsheet is lost.
False. The system automatically files any pending data when the end user changes Flowsheet templates, leaves the Flowsheets activity, closes the patient’s chart, or logs out.
If a clinician enters WDL in the “Within Defined Limits” row for a system, what does that mean?
WDL means that all values taken within that system fall within the defined range. No other data needs to be entered
True or false. Epic does not have an audit trail for values in Flowsheets that have been deities or deleted.
False. Epic does have an audit trail for edited or deleted data, and any values that have been edited or deleted are flagged.
How does a nurse document that all values are normal expect for a few?
Enter an “X” in the WDL row. (This documents that all values are within defined limits, except…) Then enter the abnormal information in the appropriate rows.
Where can a nurse look to find information ion the “defined” values for a given row?
A nurse can view the Row Information in the Details report on the right side of the screen. This gives him he information about normal values, possible choices, and the last filed data. If Details report is hidden, click the left facing arrow in the middle of the right side of the screen to expand the report.
When a nurse goes into a Flowsheet and wants to enter new values, what should be done before documenting any information to ensure the data is entered under the correct date and time?
The nurse should click the Add Col button or the Now hyperlink. This drops a new column with the current date and time. If charting values taken in the past, the Insert Col button should be used.
True or false? A nurse should always write down where she left off in her flowsheet documentation when she goes to another activity, closes the patient’s chart, or logs out and she would like to resume documenting where she left off. Otherwise, she’ll have no way of telling where she was last.
False. A nurse can tell where she last documented on each flowsheet template by the bookmark in the template’s table of contents. If she clicks Jump to where I left off, the system jumps straight to the cell under the last one she documented in.
