Care Delivery Business Rules - Children’s Health ... · Care Delivery Business Rules Children’s Health Queensland Hospital and Health Service - ii - Version history Version Date

Care Delivery Business Rules June 2019 V1.4

Care Delivery Business Rules

Children’s Health Queensland Hospital and Health Service - i -

Copyright

Copyright for all material contained in this document vests with Children’s Health Queensland. All rights

reserved. No part of this publication may be stored, reproduced or used in any manner whatever without the

express permission of the copyright holder.

Contact details

This document has been created and produced by Health Information, Children’s Health Queensland. For

information concerning the use of this material or suggestions for improvement, please contact the Health

Informatics Team via the contact details below.

Contact ieMR Team

Phone (07) 3068 1999

Email [email protected]

Document details

Document version: V1.4

Issue date: 03/06/2019


Children’s Health Queensland Hospital and Health Service - ii -

Version history

Version Date Modified By Description

V0.1 Jan 2018 Pat Dacomb Initial draft

V0.2 Jan 2018 Heather Reid Review and update

V0.3 Jan 2018 Steve Foresto Review and update

V0.4 Jan 2018 Pat Dacomb Acceptance of changes

Additional MET and IPOC content added

V0.5 Feb 2018 Pat Dacomb Updated – PICU admission and discharge, Consults, Cardiac CEWT and high flow oxygen, immunisation history, food chart, CHQ at Home, HBCIS updates

V0.6 Mar 2018 Pat Dacomb Updated – NBM orders, AB review

V0.7 Mar 2018 Pat Dacomb Updated – MW review, DB review

V0.8 Mar 2018 Pat Dacomb Updated – LJ review

V0.9 Mar 2018 Pat Dacomb Updated – RT review – Published

V1.0 Mar 2018 Pat Dacomb Updated seizure documentation

V1.1 April 2018 Pat Dacomb Updated CHQ at Home/PPCS/PACS rules

V1.2 May 2018 Pat Dacomb Updated Allied Health Workflow rules

V1.3 June 2018 Pat Dacomb Updated information on system task for patient care and consult orders and IPOC’s after discharge

V1.4 June 2019 Loretta Johnston Updated information related to Allied Health MPTL workflow for indirect client contact.

Review history

Version Date Reviewed By Position

V0.2 Jan 2018 Heather Reid Review and update

V0.3 Jan 2018 Steve Foresto Review and update

V0.5 27/02/2018 Linda Thorburn Subject Matter Expert - Emergency

V0.5 02/03/2018 Andrew Blanch Medical Lead ieMR Advanced Project CHQ

V0.5 05/03/2018 Dannica Bell Subject Matter Expert – Nursing

V0.6 05/03/2018 Megan Watt Subject Matter Expert – Nursing

V0.7 15/03/2018 Loretta Johnston Clinical Change Lead/Subject Matter Expert – Allied Health

V0.8 21/03/2018 Rachel Thomas Clinical Leader – Patient Flow, Physiotherapy


Children’s Health Queensland Hospital and Health Service - iii -

Table of contents

Care Delivery Business Rules .............................................................................5

Purpose ............................................................................................................... 5

Scope .................................................................................................................. 5

Related Documents ............................................................................................. 5

Pre-Arrival to Inpatient Unit .................................................................................5

Planning of care prior to a planned admission ...................................................... 5

Encounters........................................................................................................... 6

Admission to Inpatient Unit ..................................................................................6

Admission via Emergency Department ................................................................ 6

Direct Admission via Intensive Care Unit or Operating Theatre ............................ 6

Planned admission ............................................................................................... 7

Use of devices during transfer of patients within the facility .................................. 7

Clinical Handover ................................................................................................7

Nursing ward handover ........................................................................................ 7

Nursing patient handover ..................................................................................... 8

Allied Health ......................................................................................................... 9

Medical Officers ................................................................................................... 9

Initial Assessment Documentation .................................................................... 10

Medical Officers ................................................................................................. 10

Nursing .............................................................................................................. 11

Allied Health ....................................................................................................... 12

Treatment/Ongoing Assessment ....................................................................... 13

Review Patient Record....................................................................................... 13

Isolation Orders ................................................................................................. 14

Expected Date of Discharge .............................................................................. 14

Request for nurse special .................................................................................. 14

Non-Invasive Ventilation .................................................................................... 14

Diet Orders ........................................................................................................ 15

Nil by Mouth orders ............................................................................................ 15

Safety Management ........................................................................................... 15

Patient Care Orders ........................................................................................... 15

PowerPlans ........................................................................................................ 16

Favourites folders .............................................................................................. 17

Consults ............................................................................................................. 17 Allied Health Consults ............................................................................... 17

Allied Health Workflow ....................................................................................... 19

Documentation of nursing assessment .............................................................. 21

Creating an Inpatient Progress Note .................................................................. 21

Documentation of vital signs .............................................................................. 23 Documentation .......................................................................................... 23 Early warning alerts .................................................................................. 24 Viewing trends of vital signs ...................................................................... 26


Children’s Health Queensland Hospital and Health Service - iv -

Alteration of calling criteria ........................................................................ 26 Not for Rapid Response ............................................................................ 27

Medical Emergency Team (MET) Call Documentation ....................................... 27

Specialty Observations ...................................................................................... 28

Patients of concern ............................................................................................ 28

Blood Products .................................................................................................. 28 Transfusion reactions ................................................................................ 28 Blood product orders ................................................................................. 29

Fluid Balance ..................................................................................................... 29 Lines/tubes/drains ..................................................................................... 30

Food Chart ......................................................................................................... 31

Infant feeding ..................................................................................................... 31

Immunisation History ......................................................................................... 31

Patient on leave ................................................................................................. 32

CHQ at Home .................................................................................................... 32

PACS workflow (Post-acute care service) & Hospital Avoidance ....................... 32 Non-palliative care patients ....................................................................... 32 Palliative care patients (PPCS) ................................................................. 33

PICU Admission and Discharge Processes........................................................ 33 Admission to PICU .................................................................................... 33 Discharge from PICU ................................................................................ 33

Case Conference ............................................................................................... 34

Discharge .......................................................................................................... 34

Other relevant documents .................................................................................. 35

Appendices ....................................................................................................... 36

Appendix 1 – Nursing Admission documentation ............................................... 36

Appendix 2 - Documentation of nursing assessments ........................................ 37 Bowel Chart .............................................................................................. 37 Basic Spinal Observation Chart ................................................................ 38 Blood and Urine Observations – Ketogenic Diet Only ............................... 39 Blood Glucose Graph ................................................................................ 40 CEWTS ..................................................................................................... 41 Clinical Rounding Log ............................................................................... 42 CVAD Daily Assessment .......................................................................... 43 Intracranial Pressure Recordings .............................................................. 44 Neurological Assessment Chart ................................................................ 45 Neurovascular Observation Chart – Lower Limb ....................................... 46 Neurovascular Observation Chart – Upper Limb ....................................... 47 Radiant warmer ........................................................................................ 48 Phototherapy Observation Chart ............................................................... 49 Point of Care Testing ................................................................................ 50 Respiratory Observation Chart .................................................................. 51 Seizure Chart ............................................................................................ 52 Weight Chart ............................................................................................. 53 CPAP/BiPAP............................................................................................. 54

Appendix 3 - IPOC suggested automatically when documentation is entered .... 55

Glossary and Abbreviations .............................................................................. 63


Page 5 of 64 Children’s Health Queensland Hospital and Health Service


Purpose

The purpose of this document is to detail new business rules that apply to documentation

within the ieMR.

Scope

The scope of this document is to identify and define the new business rules applicable when

ieMR Advanced is implemented.

This document applies to the following stakeholders, but is not limited to:

• Inpatient Teams and Units (IPU)

• Patient Flow Unit (PFSU)

• Outpatient Teams and Units (OP)

Related Documents

• LCCH Digital Release General Business Rules

• Business continuity plan

• Training guides

• Quick reference guides

While clinicians have been trained in the recommended methods of documenting in ieMR, it

is acknowledged that there may be more than one way to document in ieMR which results in

the same outcome. Should a clinician use an alternative way to perform actions or

documentation in ieMR, the clinician is responsible for ensuring that the outcome/

documentation achieves the same result and patient safety is maintained.

Pre-Arrival to Inpatient Unit

Planning of care prior to a planned admission

• A pre-arrival encounter may be created to capture and manage pre-arrival information

and planning of care related to a planned admission such as planned surgery or

planned treatment.

• Orders to be commenced at admission or at other phases of the patient journey may

be planned and documented during the pre-arrival encounter in a cross-encounter

PowerPlan.

• Orders will be placed by the appropriate clinician (by scope of practice)

• Prescribers will plan and sign medication and care orders for a patient via a Cross

Encounter PowerPlan (when clinically appropriate)



• Prescribers will document, via an ieMR Progress Note, the plan for when Cross

Encounter PowerPlan (medication and care orders) are to be commenced for the

patient

• The following two items must be clearly documented in the ‘go ahead’ progress note

by the medical officer:

1. When the PowerPlan should be initiated

2. Who is authorised initiate the PowerPlan e.g. nurse, medical officer etc.

Encounters

• Documentation should be entered against the appropriate encounter.

• Where a patient remains on an outpatient encounter then documentation is to be

done in the outpatient encounter

• Once an inpatient encounter is created, all documentation during the inpatient stay

should occur in the inpatient encounter

• Should an inpatient need to attend outpatients clinic during the inpatient stay, they

are to remain on the inpatient encounter, with documentation being documented by

the outpatients clinician directly into the current inpatient encounter

Admission to Inpatient Unit

Admission via Emergency Department

• On departure from Emergency Department and prior to arrival to the ward, the

location of the patient must be updated in HBCIS to reflect the new inpatient ward in

order to trigger the admission documentation tasks for the nursing staff.

• A patient who is admitted via the emergency department will keep the same patient

identification wristband as the emergency encounter will be converted into an

inpatient encounter.

• The patient identification wristband should be checked and an ieMR wristband

applied if required.

• The FirstNet tracking board (the whiteboard) will be used for viewing patients awaiting

inpatient admission via Emergency, in replacement of Emergency view in Patient

Flow Manager (PFM).

Direct Admission via Intensive Care Unit or Operating

Theatre

• On arrival to the ward, the location of the patient must be updated in HBCIS

immediately to reflect the new inpatient ward in order to trigger the admission

documentation tasks for the nursing staff.

• The patient identification wristband should be checked and an inpatient ieMR

wristband applied if required.



• As a minimum, the transferring unit will update the ieMR with the last set of vital

signs, the fluid balance, any inserted lines and devices and will document a progress

note prior to transfer to the inpatient ward

• Any documentation on paper will be placed in the bedside chart or the CEC

• If the patient is admitted after hours or when no ward administration clerk is available,

the admission or transfer will be done by the Emergency Department Administration

Officer

Planned admission

• On arrival to the ward, the patient must be registered and admitted in HBCIS

immediately to trigger the admission documentation tasks for the nursing staff. Refer

to initial assessment documentation section.

• All admissions are to have an inpatient ieMR patient identification wristband applied

for the duration of the inpatient stay

• If the patient is admitted after hours or when no ward administration clerk is available,

the admission or transfer will be done by the Emergency Department Administration

Officer

Use of devices during transfer of patients within the facility

• When transferring patients within the hospital, nurses will not be required to

document during transfer and as such will not be required to take a laptop or other

device to access ieMR.

• Retrospective documentation can occur once patient has reached transfer

destination, (e.g. radiology or OPD) if required

• In the event of deterioration, nursing priority will remain with patient safety – i.e. get

patient to an appropriate environment to manage deterioration and initiate MET as

required.

Clinical Handover

Nursing ward handover

• Printed handover sheets from external systems may supplement CareCompass

during ward handover

o With CareCompass open, select the patient list required for the ward

handover

o Review the list, noting which patients have isolation precautions – indicated

with a biohazard icon – hover to discover the details relating to the isolation

precautions



Nursing patient handover

• Nursing shift to shift handover and handover between emergency/PICU/Operating

theatre nurse to inpatient nurse will be facilitated using the ieMR (Patient Summary

view) and the bedside chart (if necessary) in the SBAR format.

• With both nurses viewing the ieMR Patient Summary view, the nurses will:

o verbally confirm the patient’s name, date of birth and UR number corresponds

to the patient’s wristband

o review the Situation Background tab, including alerts and problems, allergies

and history, flagged events and outstanding orders

o review the Assessment tab, including the vital signs, results, medications, fluid

balance, lines and drains and any documentation

o review the Recommendation tab, including the Plan of Care

• Nurse to nurse handover will be documented in the Paediatric Quick View/Nursing

Handover Communication section in the interactive view. This includes handover on

patient transfer and shift to shift handover.

.



Allied Health

• The Multi Patient Task List (MPTL) in ieMR will be used during handover as the

current inpatient caseload list for the Allied Health professions using ieMR MPTL.

• Handover by Allied Health clinicians will be facilitated using the ieMR (Patient

Summary view) and the bedside chart (if necessary) in the SBAR format

Medical Officers

• The Doctor Patient List and the Patient Summary in ieMR will be used during

handover and ward rounds

• Documentation of tasks and actions will be documented in iPass on the ieMR Doctor

Patient List to provide visibility to other medical officers within the team

• The Doctor Patient List can be printed to include the detail entered in i-PASS

• Handover sheets from external systems may supplement the ieMR Doctor Patient

List



Initial Assessment Documentation

Medical Officers

• Medical officers will use the Doctor view/Admit tab workflow page to:

• view previously entered history, documentation, vital signs, fluid balance,

growth chart, home medications and results

• place orders

• document History of Present Illness, Physical Exam and Assessment and

Management Plan

• The Admission Note Paediatric template will be used to create the admission note.

This will pull in the following items that have been both viewed and entered via the

Doctor view/Admit tab.



Nursing

• On admission to the ward, the ieMR will automatically place tasks on CareCompass

for nursing admission documentation. This is known as the ‘Admission Rule’.

• The following inpatient locations will have the Admission Rule turned on

• Emergency Short Stay Unit 1C

• Medical Inpatient Unit 10A

• Cardiac Unit 10B

• Neuroscience and Ortho Unit 11A

• Oncology Unit 11B

• Allergy and Immunology Admissions

• Surgical Admissions 4B

• Surgical Day Unit 4C

• Respiratory and Sleep Unit 5A

• Medical Day Unit 5B

• Oncology Day Unit 5C

• Surgical Unit 5D

• Rehabilitation Subacute Unit 8A

• Mental Health Adolescent Unit 8BA

• Mental Health Child Unit 8BC

• Medical Unit 9A

• Babies Unit 9B

• The following tasks will allow documentation of the Initial Clinical Assessment and

Risk Screening in the ieMR

• The paediatric assessments will be used to document admission history, assessment

and risk assessment, regardless of the age of the patient

• The nursing admission documentation is comprehensive. The nurses will document

the same items in ieMR as per the current paper admission documentation (Appendix

1). Any additional information will be documented in a progress note



• The Substance Use Paediatric will not be ordered for patients under the age of 11

years but can be accessed from the Adhoc forms folder for documentation if required

• On admission to all inpatient wards, the Admission Rule will automatically suggest

Interdisciplinary plans of care (IPOC)

• Paediatric Hygiene Plan of Care

• Paediatric Complex Care Plan of Care

• Paediatric Family Centred Care Plan of Care

• Impaired Respiratory Status Plan of Care

• Paediatric Routines/Behaviours Plan of Care

• Impaired Communication Plan of Care

• All inpatients are to have the Paediatric Hygiene IPOC and the Paediatric Family

Centred IPOC initiated and adapted to the individual patient requirements, with the

exception of Emergency Department Short Stay Unit, Operating Theatre and

Intensive Care Unit

• Additional IPOC’s are to be initiated according to the individual patient requirements

• Additional IPOCs may be suggested by the system dependant on results of

assessments – see Appendix 3

• Patients over 18 years will have the Paediatric IPOC suggested on admission.

Should the Paediatric IPOC not be automatically suggested, the admitting nurse is to

manually order the Paediatric IPOC in order to initiate the Paediatric Hygiene IPOC

and the Paediatric Family Centred IPOC’s

• If an IPOC has been suggested but is not appropriate to be initiated, it is

recommended to leave the IPOC’s in a suggested state for the duration of the

patient's stay. The reason for this is the plans DO NOT re-suggest during the current

inpatient encounter.

Allied Health

• Allied Health clinicians (with the exception of QPRS and CYMHS) will use the Multi

Patient Task List (MPTL) to receive inpatient referrals and maintain caseloads

• Allied Health clinicians working across teams who have patient caseloads in

numerous locations, admitted under varied teams will create and maintain a custom

patient list and/or use additional comment naming conventions to assist in easily

filtering caseload list

• Documentation within the patient chart will continue to be on progress notes, with

some professions entering data into interactive view and/or PowerForms



• Any inpatient documentation on paper will be placed in the bedside chart or the CEC

• Any outpatient documentation on paper will be sent to the scanning unit directly as

per current practice

• Allied Health staff may contribute to patient specific goals and interventions in

initiated Interdisciplinary Plans of Care (IPOC) after collaboration with nursing staff.

Only interventions that are not available as patient care orders should be included in

an IPOC

• Allied Health may use the ‘flagged event’ feature in Interactive View to inform nursing

staff of a patient’s mobility status. This is to be updated or removed by the Allied

Health/nursing clinician when no longer applicable

Treatment/Ongoing Assessment

Review Patient Record

• When reviewing the patient chart, clinicians are to be aware that the patient may

have:

o a bedside chart that contains some paper documentation that is not able to be

entered in ieMR until scanning on discharge

o a CHARM record

o a CIMHA record

o a MetaVision summary

• Assessment and treatment documentation entered in Emergency Department via

FirstNet will be visible in the ieMR

• The Patient Summary view draws information from various places in the patient chart

into an SBAR format into components called ‘widgets’

• It is important to view the criterion that has been used to populate the Patient

Summary widgets. If the criteria used does not display all the required information,

the clinician should navigate to the area of the ieMR chart that contains the full history

• It is important to view the date and time stamp associated with information pulled into

the Patient Summary widgets, in particular in the Vital Signs widget, where the EW

Score may not correlate with the observations directly below it as this component

draws in the last 3 instances of each recorded observation



Isolation Orders

• If the patient requires isolation, a ‘Patient Isolation’ order is placed on the patient

chart

• The following precautions exist in the ieMR under ‘Patient Isolation’

o Airborne Precautions

o Contact and Airborne Precautions

o Contact Precautions

o Cytotoxic Precautions

o Droplet Precautions

o Pink Precautions – Cystic Fibrosis Isolation

o Protective Isolation

• If a child has multiple precautions required, e.g. Cytotoxic Precautions and Contact

Precautions, then two isolation orders will be placed

• If additional clarification is required, e.g. Pink 1 or Pink 2 precautions for cystic

fibrosis patients, the ‘Order Comments’ field will be used to document this information

• The isolation order should be completed when isolation is no longer required.

Expected Date of Discharge

• The expected date of discharge is entered in the Paediatric Quick View Interactive

View band. This date displays on care compass (note the date format is American)

and also displays on the discharge tab of the Patient Summary view

Request for nurse special

• Ordering/documentation of specials 1:1 or 1:2 will stay on PFM post go live.

Non-Invasive Ventilation

• Orders for non-invasive ventilation will remain on paper and be scanned into ieMR as

per current practice



• The nursing documentation regarding NIV will transition to ieMR and be documented

in Interactive View. The CPAP/BiPAP band within Interactive View will be used to

document this information

Diet Orders

• PFM will continue to be used by Nursing and Allied Health to order patient

diets/formula from the kitchen/formula room

Nil by Mouth orders

• Nil By Mouth orders can be placed in ieMR via Orders

• Medical Officers will communicate to the patient’s treating team and document the Nil

By Mouth status in the clinical notes

• The nurse caring for the patient will place the Nil by Mouth order in ieMR, using the

convention of S 0200, CF 0600, F 0400 – S = Solids, CF = Clear Fluids, F = Fasting

Safety Management

• Nurses will document against the Safety Management Interactive View band at the

start of every shift in conjunction with bedside handover

• Nurses are required to document all relevant information for each patient

appropriately within the safety management iView band

Patient Care Orders

• Patient care orders should be used to aid in the communication of the plan of care to

all staff involved in the patient’s care. When a clinician places a care order an

associated task will be displayed on CareCompass to be actioned by nursing staff.

• Patient care orders should be reviewed as the patient’s care needs change, at the

handover of care of the patient, prior to transfer to non-ieMR wards and prior to

discharge

• Once only, prn and scheduled patient care orders will be documented by placing an

order in the patient’s chart

• Nurses are to ensure a daily task is ordered for Glamorgan – pressure injury

assessment. Note that if the documented Glamorgan score is >10, an automatic

daily task is fired on chart, but if the score is <10, the nurse needs to set up a daily

task for Glamorgan assessment. As a result there is the possibility that a patient may

have two orders for Glamorgan assessment, one of these should be cancelled as the

system will fire two tasks to CareCompass

• Nurses are to ensure that a Safety Check care order is place for twice a day (0800

and 2000). This task will fall onto CareCompass at 0700 and 1900. It will become

overdue at 0900 and 2100.

• If a required patient care order is not available in the order catalogue, this should be

documented in a progress note and communicated verbally to the nursing staff

• Placing patient care orders in ieMR does not negate the need for verbal

communication



• Allied Health staff may place patient care orders in consultation with nursing staff. All

care orders should be placed as ‘PRN’ with special instructions outlining timing of

tasks. The exception to this is patients of concern requiring suctioning – these tasks

may be scheduled to in consultation with nursing staff

• Patient care orders should be modified when the details of the order require updating

or cancel/discontinued when no longer required

• Nursing documentation against patient care orders should be done through

CareCompass in order to:

o maintain the accuracy of the CareCompass Activity Timeline

o assist with the location of the correct place to document in the patient chart

o alert clinicians to overdue tasks

PowerPlans

PowerPlans are pre-defined sets of orders that can be modified according to patient

requirements.

• PowerPlans will be placed by the appropriate clinician (by scope of practice)

• Prescribers will plan and sign medication orders for a patient via a either a pre-

populated Statewide PowerPlan or a Cross Encounter PowerPlan (when clinically

appropriate)

• Prescribers to document, via an ieMR Progress Note, the plan for when the

PowerPlan is to be commenced for the patient and who can initiate the PowerPlan

(e.g. medical officer, nurse)

• Nursing staff are to initiate either the Cross Encounter PowerPlan/Phase at the

clinically required time after referring to the specific instructions within the

Prescriber’s Progress Note (i.e. a future outpatient/inpatient encounter)



• If details in the PowerPlan are not complete (for example doses for medication

orders), nurses will not initiate the plan. The nurse is to contact the relevant medical

officer to complete the details before progressing

• The use of a PowerPlan does not negate the initiation of a paper Clinical Pathway if

this is required

Favourites folders

• Within each clinical speciality, a senior doctor (prescriber) will own the processes and

manage the favourite’s folder (Custodianship), and they will make the favourite’s

folder orders/PowerPlans available to fellow clinicians of that clinical service. It will

be the custodian’s responsibility to ensure their shared PowerPlan favourite’s folder is

kept up to date

• If a PowerPlan is modified and saved as a favourite, it should be re-named to reflect

that the PowerPlan has been modified

• End users with the physician indicator (mostly medical officers) are able to share their

favourites including PowerPlans that have been modified

• The favourite’s functionality pertains to PowerPlans and not to individual medicines,

whose order sentences are updated routinely without notifications to end-users. The

modification of PowerPlans is associated with a notification message.

Consults

• Referrals are called ‘Consults’ in ieMR and are placed using the New Order function

• ieMR consult orders are used for inpatient and emergency patients only

• Consults to Acute Pain Service will be made using the ‘Consult to Acute Pain Service’

order. The consult order list for Acute Pain Service will be monitored by the Acute

Pain Service CNC.

• Consults to Specialty Medical services for inpatients may be made on ieMR but

always need to be followed up by a phone call as the consult order list is not

monitored (for example, Consult to Cardiology)

Allied Health Consults

• Consults to the following in-scope Allied Health professions will be placed in ieMR by

the clinician requesting the consult.

o Physiotherapy

o Speech Pathology

o Dietetics

o Social Work

o Occupational Therapy

o Audiology

o Psychology

o Neuropsychology



o Music Therapy

o Welfare

o ATSI (Indigenous Health) Liaison Officer

• Consults are not to be requested in PFM for the in-scope Allied Health disciplines

• Staff requesting Allied Health service via phone/pager/email/case conference will be

requested to place a consult order in ieMR

• Placing consults to Allied Health in ieMR does not negate the need for verbal

communication

• The ‘Priority’ area of the consult order is to be left blank by referrer – Allied Health

staff will determine priority in more detail than urgent/routine

• If a consult is required after hours (by on-call emergency) or is urgent, a phone

call/page will be made to Allied Health to request urgent consultation in addition to the

consult being placed in ieMR

• On-call emergency consults will have an 'urgent' priority designated with special

instruction to be completed. If on-call service is provided via phone, doctors/nurses

will place the consult order and mark this as complete on behalf of AH staff member.

This will make it clear for staff reviewing the chart, that the consult has been

completed.

• All inpatient reviews to be ordered by Allied Health staff as 'Follow-up to…'

• Blanket referral processes should be processed in accordance with already

established protocols and will be entered as initial 'Consult to…' by Allied Health staff.

• The following disciplines are not receiving consults in ieMR (out of scope) and the

method of referral remains unchanged:

o Sciences – cardiac, respiratory, sleep, neuro

o Anaesthetic Technician

o Medical imaging

o QPRS

o CYMHS

o Persistent Pain



Allied Health Workflow

• Allied Health departments that are in scope of ieMR consults will assign a staff

member to monitor ieMR for new inpatient referrals during the day

• When a new consult is received, Allied Health staff will review the consult information

and action the task as required

• Once an initial consult has been completed, ongoing care within the same inpatient

admission is a “follow up” on ieMR.

• A follow up order should be entered for each inpatient review completed. For

example, if an inpatient is seen three times in one day, three follow up orders need to

be entered or the appropriate frequency and due time applied to the follow up order

• Patients who are regularly admitted should have a Consult order placed each time

there is a new admission, and follow up orders thereafter

• After initial consult, when transferring a patient to a different stream in the same

department, follow up orders are to be placed, not a new consult order

• Re-referral within the same encounter - if an inpatient has been discharged from an Allied Health inpatient service, then is re-referred within the same admission this is considered a new referral therefore another ‘Consult to…’ needs to be added as the patient is being referred for a new issue that has been identified.

• A consult and follow up order should only be marked as completed once a patient has

been seen.

• Follow up orders that are no longer required can be cancel/discontinued.

• All follow up reviews to be ordered by Allied Health staff as 'Follow-up to…’ using the

orders functionality in ieMR

• Each Allied Health profession will establish local business rules regarding

rescheduling inpatient consults and placing follow up orders

• Allied Health staff will use a standardised naming convention to fill in the ‘Additional

Comments’ on the Consult and follow up orders to assist with

allocation/triage/handover

• Allied Health staff will use the ‘Order Comments’ on the consult and follow up orders

to assist with detailed clinical handover

• Allied Health consults done via phone by on-call emergency staff will be documented

in ieMR via consult order (placed by requesting clinician) and a progress note will be

entered by the on-call staff when access to ieMR is obtained

• Discharge readiness to be communicated via progress notes and discussions with

treating team

• Allied Health staff will use the MPTL ‘Chart Not Done’ function only when declining

referrals. Allied Health staff will continue to write a progress note and advise referrer

directly regarding any declined referrals

• The functionality of ‘Admin note’ on the consult and follow up orders is to be used

only for inter-team/inter-department communication. No clinical information is to be

included in the admin note



• Allied Health staff will not document in Home Medications functionality in ieMR. Allied

Health staff may comment on home medications in the progress note.

• When a patient is discharged, the ieMR automatically cancels/discontinue any

outstanding orders associated with that encounter after approximately 2hours –

48hours. The longer time is often associated to orders that are placed accidentally

against already discharged encounters.

• Any follow up/consult orders which are still outstanding and have not been charted as

“done” could be cancelled automatically as soon as 2 hours after discharge, and

therefore won’t be seen on the completed activity report in CHIRP.

• Chart activities as Done as soon as possible for patients on day of discharge to

ensure data accuracy. It would be good practice to do this where possible for all

patients.

• If you know a patient has been discharged and a consult or follow-up task is still

appearing on MPTL, you can cancel/discontinue the order from the orders screen

Indirect Client Contact

• Providing handover to another service in either preparation for patient discharge or

for an already discharged patient: if greater than 15minutes and included as part of a

plan in previous chart entries of treatment documentation, mark order as complete on

MPTL if currently an inpatient. If already discharged, related to inpatient admission

and handover to new service, may complete one further follow-up order on MPTL.

Subsequent interventions not to be recorded on MPTL.

• Chart review (plus ieMR progress note written) of a current inpatient to determine

when direct review is indicated: mark order as complete on MPTL.

• Chart review (no ieMR progress note written) of a current inpatient to determine when

direct review is indicated: do not mark the order as complete on MPTL as it is unlikely

to be greater than 15mins in duration and no documentation of this occurring. If on

MPTL as reminder/flag – please reschedule task as required. When documentation

written, complete order on MPTL and reorder as required.

• Planning services for a current inpatient (e.g. mass application for equipment): if

greater than 15mins and included as part of plan in previous chart entries of

treatment documentation mark order as complete on MPTL.

• MDT/case conference when inpatient not present: if contributing to clinical

information/update/handover and time spent on patient >15mins, ieMR progress note

must documented, complete MPTL. Do not complete MPTL if e.g. attending ward

round ‘out-of-interest’.

• Participation in team meetings (e.g. infant team meeting) do not mark order as

complete on MPTL as unlikely to > 15mins in duration on specific patient and no

documentation of this occurring in ieMR.



• Report writing for inpatient assessments: if greater than 15mins and included as part

of plan in previous chart entries, complete MPTL.

• Developing bedside inpatient therapy program to be delivered by parent or AHA: if

greater than 15mins and included as part of plan in previous chart entries, mark order

as complete on MPTL. When initial ‘handover’ session is provided to AHA, MPTL

completed for both clinician and AHA. Subsequent AHA only sessions, complete

MPTL only for AHA. Feedback, training and upskilling of AHA’s as part of their

learning is not in scope for MPTL.

• Attempted Review (inpatient sleeping or off-ward (+/- progress note written to

indicated attempted review)): if a progress note is written and time spent is greater

than 15minutes mark order as complete on MPTL. If no progress note is written in

ieMR and <15mins spent do not mark order as complete on MPTL and reschedule or

cancel/discontinue/reorder.

Documentation of nursing assessment

• Documentation of nursing assessments will be done in ieMR using Interactive View or

PowerForms

• A number of paper forms will no longer be used. A list of commonly used paper

assessment forms that will be documented in ieMR can be found in Appendix 2

• During downtime, documentation of nursing assessments will be done using paper

forms in the downtime procedure box

• An item in Interactive View can be flagged to display in the Patient Summary view.

All flagged events must be manually maintained (i.e. unflagged or new event flagged

to reflect current status)

• If a nurse is working in a location where the Interactive View bands do not default to

paediatric content, the nurse will manually add the paediatric Interactive View bands

in the following order:

• Paediatric Quick View

• Paediatric Systems Assessment

• Fluid Balance

• Paediatric Lines & Devices

• Paediatric Risk Assessment

• Education

• Blood Administration

• Preoperative Checklist

• Additional Interactive View navigator bands are available to be manually

added as required.

Creating an Inpatient Progress Note



• The clinician will create an Inpatient Progress Note in order to document:

• Clinical care activities performed for the patient that is not captured in other areas of

the patient’s electronic medical record

• Changes in condition and treatment response

• Any information that is necessary for other clinicians to refer to

• A new progress note should be created for any new information. This ensures that all

documentation from multiple clinicians remains in chronological order.

• Additional information or changes pertinent to a previously written note can be added

as an addendum.

• Refer to the Progress Notes section of the Digital Release General Business Rules

document for further guidelines such as naming conventions.



Documentation of vital signs

Documentation

• Vital signs for all patients (with the exception of patients in Emergency/ESSU and

cardiac patients admitted to ward 10B) are to be documented on the Managing

Deterioration Observation PowerForm in ieMR

• Patients within the cardiac cohort in ward 10B will continue to be documented on the

Children’s Early Warning Tool (CEWT) CARDIAC (trial form)

• Cardiac patients who have been admitted to inpatient units other than 10B will have

their vital signs documented via Managing Deterioration

• Non-cardiac patients who are admitted to ward 10B will have their vital signs

documented via Managing Deterioration

• When regular vital signs are ordered as a task that appears on CareCompass, these

are to be documented in the Managing Deterioration Observation PowerForm, despite

the task routing the end user to Interactive View. The vital signs task is to be marked

as ‘Done’ on CareCompass when the task is complete

• ieMR will automatically determine the appropriate CEWT age range to apply to the

patient (i.e. less than 1 Year, 1-4 Years, 5-11 Years, 12 Years and Over)

• Patients who are 16 years and over will be measured against the Q-ADDs parameters

in ieMR

• The Managing Deterioration Observation PowerForm allows for documentation of an

axilla temperature. Nurses may use this field to document a tympanic temperature and

add a comment to notate that the temperature recorded was a tympanic temperature

• The tab labelled General Neurological Assessment on the Managing Deterioration

PowerForm should not be used to document neurological observations for paediatric

patients. A care order should be placed for Neurological Observations Paediatric and

the nurse should use the CareCompass task to access Interactive View. By accessing

the assessment task in this manner, age-appropriate assessment descriptors will be

visible to the end user

• If observations in addition to those that contribute to a CEWT/QADDS score require

documentation (for example: mode of oxygen delivery or positional BP), these are to

be recorded in Interactive View

• Clinicians are able to generate a Mean Arterial Pressure (MAP) by entering the

patient’s blood pressure via the Managing Deterioration Observation PowerForm and

then navigating to Vital Signs tab of Interactive View and double clicking in the “Mean

Arterial Pressure cuff calc” field. This will automatically calculate the patients MAP in

mmHg. A manual MAP may also be entered if the clinician wished to use the MAP

reading from a vital signs machine

• High flow oxygen therapy will be recorded in Interactive View. Currently the FiO2 data

point within Interactive View does not contribute towards the patients CEWT score.

This will be managed in the interim by the documentation of the patient’s wall oxygen

flow rate within the Managing Deterioration Observation PowerForm until changes can

be made within the system to accurately reflect the patients FiO2 within their calculated

CEWT score



• When a patient is randomised onto the PARIS II trial, an alert is to be placed on the

patients chart by either the ED staff or by the ward nurse

• Documentation of observations for procedural sedation will be done using the

Managing Deterioration observations PowerForm. The sedation score can be

documented on the adult side of the PowerForm and this will write to the Interactive

view

Early warning alerts

• A full set of vital signs is required to generate a CEWT/QADDS score in ieMR

• The following vital signs are required to be completed in ieMR to generate a CEWT

score:

• Respiratory rate

• Respiratory distress

• O2 Flow rate

• SpO2

• Temperature (or Temperature not assessed)

• Peripheral Pulse Rate

• Capillary Refill

• AVPU (or AVPU not assessed)

• Temperature not assessed and AVPU not assessed may be used in place of

temperature and AVPU for patients under 16 years. The clinician is to add a comment

if the not assessed DTA is used

• The nurse should use the appropriate side of the PowerForm for the patient age group

to ensure that the appropriate data points are recorded against to calculate an early

warning score



• The following vital signs are required to be completed in ieMR to generate a QADDS

score:

• Respiratory rate

• O2 Flow rate

• SpO2

• Temperature

• Peripheral Pulse Rate

• Blood Pressure

• AVPU

• Temperature not assessed and AVPU not assessed will not generate a QADDS score

when used in place of temperature and AVPU for patients over 16 years

• If there are insufficient observations entered to generate a CEWT/QADDS score, a

discern alert will be triggered

• Should the CEWT/QADDS be 1 or more, a discern alert will appear, which details the

actions required for the related score



Viewing trends of vital signs

• After documenting vital signs, the clinician is required to view the vital signs trend on

the Managing Deterioration view

• If the observations fall within the blue, yellow or red bands on the Managing

Deterioration view, a corresponding symbol will display alongside the observation and

yellow or red alerts will display

• If a yellow or red alert is displayed, the clinician is required to acknowledge and

suspend the alert for 0 minutes only

Alteration of calling criteria

• If out of age-specific range vital signs are expected for a patient, modifications to

these ranges are documented by the clinician (usually medical officer by scope of

practice) on the ieMR, via the ACC hyperlink on the Managing Deterioration view



• Name of authorising Medical Officer for the Altered Calling Criteria page should be

the person who is filling in the Altering Calling Criteria form. If it is not within the

author's scope of practice alter the calling criteria, then document the name of the

doctor who has been consulted for the decision.

• The tick box for 'Use attending doctor' is not to be used unless the attending doctor

has been consulted

• If Calling Criteria are altered it is recommended that a comment is entered into the

Comments box e.g. cyanotic heart disease

Not for Rapid Response

• The tick box “Not for Rapid Response” in the ACC link on the Managing Deterioration

page will not be used

Medical Emergency Team (MET) Call Documentation

• During a MET call, the MET Nursing Team Leader/Scribe will document all

interventions and care tasks that have occurred during the MET call on the

Resuscitation Data Sheet. This may include, but is not limited to: suctioning,

nasogastric insertion, IVC insertion, application of oxygen or high flow therapies, POC

tests such as BGL or ketone levels as per current process

• The patient record in ieMR is to be opened/remain open during the MET attendance,

for ease of viewing information and ordering of pathology/radiology tests

• If the patient is to remain on the inpatient ward once the MET call has been stood

down, the bedside nurse responsible for the patients’ care will be required to

retrospectively enter these interventions and/or create dynamic groups for care tasks

that were carried out during the MET call

• If the patient is to be transferred from the inpatient ward to the Paediatric Intensive

Care Unit, the bedside nurse will not be required to retrospectively document the care

tasks carried out during the MET call, however must ensure that what has been

recorded on the Resuscitation Data Sheet is an accurate representation of the MET

call, as this will be scanned into the patients chart as per current process.



Specialty Observations

• Patient care orders should be placed for the following specialty observations to

ensure documentation is made in the correct place in the chart, that paediatric

scoring tools are used and to document care planning:

• PCA/ NCA Routine Observations Paediatric

• Pain Assessment Paediatric

• Respiratory Observations Paediatric

• Lying and Standing Blood Pressures

• Lower Limb Neurovascular Observations Paediatric

• Upper Limb Neurovascular Observations Paediatric

• Neurological Observations Paediatric

▪ The tab labelled General Neurological Assessment on the Managing

Deterioration PowerForm should not be used to document

observations for paediatric coma scale

Patients of concern

• Identification of ‘Patients of Concern’ will remain on PFM post go live until further

notice

• A Consult to Safety CNC’ will be placed to indicate Patients of Concern, using one of

the following reasons for consult:

• CEWT score

• Clinical concern

• Communication concern

• Family concern

• High risk therapies

• PARP

• Placing a ‘Consult to Safety CNC’ does not negate the need for contacting the Safety

CNC by phone

Blood Products

Transfusion reactions

• Previous history of transfusion reactions is to be documented for all patients on

admission within the Admission History Paediatric PowerForm. This will enable an

alert to fire should a blood product be ordered during the current encounter

• If a patient has a transfusion reaction while receiving a blood product, this is to be

documented in the Blood Product Administration band in Interactive View. This will

enable an alert to fire should a subsequent blood product be ordered during the

current encounter

• If a transfusion is paused (e.g. drip re-site, mild transfusion reaction) but then

restarted using the same bag of blood, the nurse should document the rate to 0 ml/hr,



enter the amount that has transfused so far, add a comment (regarding why

transfusion has been paused), then continue with the current process

• Transfusion reactions should continue to be added as an allergy in ieMR

Blood product orders

• Blood products that are not dispensed by pharmacy will continue to be ordered from

Blood Bank on paper using the Blood Transfusion Request form

• A Blood Product Administration order should be placed for the nurse to document the

administration of the blood product

• A blood product administration order should be placed for the administration in

addition to the paper order for Haemopoetic Stem Cell infusions. Nurses will be

required to document the administration against the blood order in the ieMR and on

the paper Cross Match Report

• The nurse will document that the blood product consent has been reviewed when

documenting the administration of the blood product in Interactive View

• A dynamic group must be created per unit of product. On completion of the

documentation for each unit of product, the dynamic group should be inactivated to

avoid inadvertent documentation against this group for future infusions

Fluid Balance

• Fluid balance will be recorded in ieMR via the Fluid Balance Interactive View band

• Continuous automatic totalling will occur within the Fluid Balance Chart. This will also

be visible within the Patient Summary

• The Fluid Balance will automatically total and reset at midnight



• Nurses will need to add another intake source to record infusion volumes for infusions

or medications prescribed in other systems outside of ieMR for example, those

prescribed in Metavision or chemotherapy orders that exist in CHARM

• Expected urine output and circulating blood volume can be documented in the fluid

balance interactive view. The documentation of expected urine output and circulating

blood volume will be reviewed and introduced after go live. If documentation of

expected urine output and circulating blood volume is done, then it is important to

document this each 12 hours

Lines/tubes/drains

• All lines/tubes/drains should be documented in iView by the person who inserts the

item or the treating nurse:

o If the item is inserted in theatre, the Anaesthetic Assistant (if medication

related) or the Scrub Scout (if surgical/drainage related) will document the

item via a dynamic group

o If the item is inserted in PACU or the ward, the treating nurse will document

the dynamic group

o If the item is inserted in PICU, the PICU nurse will document the dynamic

group prior to transfer to the ward

• When peripheral IV fluids are documented in ieMR, the related site checks should be

documented in the associated site check area

• The documentation of site checks for all other devices, e.g. central venous access

devices, subcutaneous lines, drains and urinary catheters, will be completed in

Interactive View – Paediatric Lines and Devices under the relevant dynamic group

• When a patient has a central venous access device, the iView section of 'Hourly IV

Infusion Device check' will be brought in (via the lipstick) for the documentation of the

CVL dynamic group and associated site checks. After documenting the fluid balance,

the nurse will navigate to and document the site check.in the 'Hourly IV Infusion

Device check'



Food Chart

• Food consumed by patients will be recorded in ieMR via the Paediatric Systems

Assessment>Activities of Daily Living>Nutrition ADL’s in Interactive View

• Fluid amounts entered in the Nutrition ADL’s will update the fluid balance and add to

the daily totals

• Food documented via Activities of Daily Living>Nutrition ADL’s in Interactive View will

update the Nutritional Deficit Plan of Care outcomes

Infant feeding

• An Enteral feed (bolus) order should be placed in order for a task for oral feeds to be

visible on CareCompass

• The Infant Feeding Interactive View section is to be pulled into the Interactive view for

infant patients

• Nurse witness of expressed breast milk should be documented in Interactive view as

per local policy

Immunisation History

• No historical vaccinations will be documented in ieMR for CHQ patients.

• The Australian Immunisation Register (AIR) is the source of truth for historical

vaccinations information

• Clinicians will need to still refer to AIR for historical vaccinations information.

• Paper-based updates to AIR will still occur for Pharmacy and ED patients as per

current clinical practice.

• The CHQ Immunisation Centre will enter information directly into AIR as per current

clinical practice.



Patient on leave

• If a patient goes on ward leave, the nurse will mark any tasks that were due while the

patient was on ward leave as ‘Not Done’, with the reason of ‘Patient unavailable –

enter comment’, and the comment of ‘Patient currently on leave from ward’

CHQ at Home

• When a patient is to be transferred to CHQ at Home from the inpatient ward, the

patient is not to be discharged in HBCIS as this will affect the orders that are in place

for medications, patient cares and labs.

• All orders (including medication and pathology orders) are to be ordered in the

Inpatient encounter

• Vital signs observations and systems assessment will be documented in ieMR as per

inpatient documentation.

• A set of vital signs will be documented each HITH visit via the Managing Deterioration

tab in PowerChart

• When documenting vital signs, the ieMR will trigger CEWT responses based on the

CEWT tertiary and secondary forms, however CHQ at Home nurses will have

appropriate decision support available to inform of the appropriate actions required

for HITH patients

• Other relevant documentation should include: central line assessment and cares in

lines and devices, daily Glamorgan assessment and any patient-specific

assessments required

• The CHQ at Home nurse will carry the relevant Child Early Warning Tool (CEWT)

paper chart to and from the home in case of downtime/nil internet access. The

patients’ observations will be documented on the CEWT paper form and transcribed

into ieMR as soon as possible (by the end of the shift) via the ‘Managing

Deterioration’ tab

• Refer to the Medications Management Business Rules document for medication

ordering, suspending, administration and reconciliation specific rules

PACS workflow (Post-acute care service) & Hospital

Avoidance

Non-palliative care patients

• Patients referred to and accepted by CHQ at Home for PACS or Hospital Avoidance

will have a chronic encounter opened for all orders and documentation

• The CHQ at Home Pharmacist/Nurse will put a placeholder on the MAR indicating

this is a chronic encounter and contains medications for HITH nurse administration

ONLY.



• The CHQ at Home team is responsible for ensuring the encounter in the patient’s

chart is closed when episode of care is completed. Episodes of care lasting longer

than 12 months (Hospital Avoidance) will be closed and re-opened prior to the 12

month mark.



Palliative care patients (PPCS)

• Patients referred to and accepted by CHQ at Home for PPCCS will have a chronic

encounter opened for documentation and pathology orders

• Medications for administration by CHQ at Home nurses will be prescribed on the

Paediatric National Inpatient Medication chart (P-NIMC) and/or approved PPCS

opioid infusion form (for example: Nikki pump infusions)

• The CHQ at Home Pharmacist/Nurse will put a placeholder on the MAR indicating

that a “**Separate record exists ** this patient has an active paper Medication

chart/infusion order” order in ieMR

o This placeholder order is located at the top of the MAR and will remain

present until the placeholder order is cancelled.

o This order should only be used for the period when there are current, active

medication orders being administered and should be discontinued outside of

these times.

• The HITH co-ordinator is responsible to ensure the encounter is closed when episode

of care is completed.



PICU Admission and Discharge Processes

Admission to PICU

• On Admission to PICU all medication and fluid orders in ieMR will be cancelled by the

admitting PICU Medical Officer

• All appropriate medication and fluid orders will be prescribed / transcribed in

MetaVision by the admitting PICU Medical Officer as per current practice.

• All Nursing Orders are cancelled by the transferring ward nursing staff at earliest

opportunity.

Discharge from PICU

• For medication related business rules, please reference the Medication Management

Business Rules document



• All Discharge paperwork, including medication and fluid orders in ieMR, to be

checked by PICU RN prior to discharge from PICU ensuring administration

scheduling times correlate with MetaVision scheduling

• PICU Nurse to enter CEWT observations, last fluid balance subtotals (IV, enteral,

urine, gastric, drains etc) into the patients Fluid Balance in ieMR

• Last dose of PRN medications administered in PICU are to be signed on the MAR for

the time they were administered with a comment ‘Documented in MetaVision by PICU

nurse’ if given within 24 hours of PICU discharge

• Any outstanding medication or nursing tasks should be reconciled prior to, or at the

time, of discharge - marked ‘administered’ with a comment – ‘Documented in

MetaVision‘

• On handover of patient to the accepting ward, all medication orders should be

checked and reconciled by the discharging PICU RN and accepting Ward RN

• Active fluid/infusions should be checked at handover and signed as an active order in

the ieMR by the discharging PICU RN, with the receiving ward RN as the witness. A

comment should be added when signing for the infusion in the ieMR that the infusion

was commenced in PICU

o NB: To reflect infusion volume remaining, infusion waste should also be

documented at time of handover

• It is the responsibility of the accepting ward nurse to unsuspend / re-order Nursing

orders.

Case Conference

• There will be no change to the current processes in place for Case Conference.

• The use of the ieMR functionality related to Case Conference and Multi-Disciplinary

Team meetings (MDT tab and the Case Conference ad hoc PowerForm) may be

implemented post-go live after further optimisation.

Discharge

• Criteria Led Discharge forms will remain on paper

• Allied health will communicate the discharge readiness via progress notes and

discussions with treating team

• The nurse responsible for discharging the patient is to review the outstanding orders

and tasks, update any initiated plans of care and reject any unneeded suggested

plans of care

• In all inpatient areas besides 4b and 4c, the nurse responsible for discharging the

patient is to complete the Discharge Checklist PowerForm prior to the patients

discharge, ensuring that all relevant questions on the checklist have been

documented against.



• The Nurse responsible for discharging the patient is still required to complete the

paper-based "Parent/Carer Discharge Checklist" form and ensure that the

parent/carer signs and leaves with a copy of this form upon discharge.

• On discharge, active patient care and consult orders will be discontinued

automatically approximately 2 hours after discharge

• On discharge, suggested plans of care will drop from the patient's chart when

rejected or 15 days post-discharge if they are not rejected during the discharge

process

Other relevant documents

• QRG

• Training materials

• CHQ ieMR Advanced intranet site



Appendices

Appendix 1 – Nursing Admission documentation



Appendix 2 - Documentation of nursing assessments

Bowel Chart

MR number 656190



Basic Spinal Observation Chart

MR number 658214 – Continue to use paper chart – to be optimised



Blood and Urine Observations – Ketogenic Diet Only

MR number 6586120

On the back of this form is the Emergency Response Plan relating to the actions that are to

be followed for patients who are on Ketogenic Diets

This form will stay on paper for the benefit of the reference text and also for parents to

document results on. The nurse will still be required to put the results into ieMR using the

Urine Dipstick POC order and associated docset



Blood Glucose Graph

MR number 656220



CEWTS

MR Number SW145, SW146, SW147, SW148

Correct age chart is automatically selected by ieMR – no need to select manually

Note: CHQ at Home have specific HITH CEWT Actions to follow for their patients while working in the field. A resource containing the actions and a copy of the actions on the desktop of their devices will be available



Clinical Rounding Log

MR Number 658692

This is being further optimised by Cairns Hospital



CVAD Daily Assessment

MR Number 657420



Intracranial Pressure Recordings

MR Number 658712

Patient Position or Activity to be documented as a comment against the ICP recording –

ACCC has been submitted to include these additional items



Neurological Assessment Chart

MR Number SW575



Neurovascular Observation Chart – Lower Limb

MR Number SW376

Pain score to be documented within the Pain tab. Ooze to be documented in comments.



Neurovascular Observation Chart – Upper Limb

MR Number SW375

Pain score to be documented within the Pain tab. Ooze to be documented in comments.



Radiant warmer

MR Number 656410



Phototherapy Observation Chart

MR Number 658336



Point of Care Testing

MR Number 656122



Respiratory Observation Chart

MR Number 656280



Seizure Chart

MR Number 656160

This will be optimised after go live to include more extensive clinical documentation of seizures for diagnostic purposes or pre-surgical workup. In the interim, the documentation of seizure assessment will remain on paper.



Weight Chart

MR Number 656140



CPAP/BiPAP

Multiple forms



Appendix 3 - IPOC suggested automatically when documentation is entered

Suggested IPOC Trigger

Alteration of Body Temperature Plan of

Care – not working on tympanic

[1] Result for 'Temperature (Axillary or Artery)' that is EQUAL TO or GREATER THAN '37.5'

or [2] Result for 'Temperature (Bladder or Rectal)' that is EQUAL TO or GREATER THAN '38.5'

or [3] Result for 'Temperature (Oral)' that is EQUAL TO or GREATER THAN '38'

or [4] Result for 'Temperature (Axillary or Artery)' that is EQUAL TO or LESS THAN '35.5'

or [5] Result for 'Temperature (Bladder or Rectal)' that is EQUAL TO or LESS THAN '36.5'

or [6] Result for 'Temperature (Oral)' that is EQUAL TO or LESS THAN '36'

AND Alteration of Body Temperature IPOC is not already 'Active' or 'Pending'

Altered Mental Status Plan of Care –

Adults only

[1] Result for 'CAM Result' that is EQUAL TO 'Positive'

or [2] Result for 'Clinical concern for cognitive function' is EQUAL TO 'Yes'

or [3] Result for 'Sleeping behaviours' is EQUAL TO 'Difficulty awakening', 'Difficulty falling asleep',

'Difficulty sleeping at night', 'Early morning awakening', 'Enuresis', 'Hypersomnia', 'Night terrors',

'Nightmares', 'Sleepwalking' or 'Reverse sleep-wake cycle'

AND Altered Mental Status IPOC is not already 'Active' or 'Pending'

Pain Management Plan of Care [1] Result for 'FLACC Score' or 'PIPP Pain Score' that is GREATER THAN '0'

or [2] Result for 'FACES pain scale at rest' is EQUAL TO '10', '8', '6', '4' or '2'

or [3] Result for 'FACES pain scale with activity' is EQUAL TO '10', '8', '6', '4' or '2'



or [4] Result for 'Numeric rating at rest' is EQUAL TO or GREATER THAN '1'

or [4] Result for 'Numeric rating with activity' is EQUAL TO or GREATER THAN '1'

AND Pain Management IPOC is not already 'Active' or 'Pending'

Alteration in Tissue Perfusion Plan of

Care

[1] Result for 'Temperature (Axillary, Oral or Tympanic' that is LESS THAN '35.6'

or [2] Result for 'Peripheral pulse rate' is LESS THAN '50'

or [3] Result for 'Skin turgor general' is EQUAL TO 'Ashen', 'Cyanosis', 'Pallor', 'Pale', 'Mottled' or

'Necrotic'

or [4] Result for 'Skin temperature' is EQUAL TO 'Cool' or 'Cold'

AND Alteration in Tissue Perfusion IPOC is not already 'Active' or 'Pending'

Risk for Aspiration Plan of Care [1] Result for 'Level of consciousness' that is EQUAL TO 'Comatose', 'Lethargic', 'Obtunded' or

'Stuporous'

or [2] Result for 'Aspiration Risk' is EQUAL TO 'Cough/frequent throat clearing with oral intake',

'Decreased ability to handle secretions', 'Difficulty swallowing liquids (ALL)', 'Difficulty swallowing

pills', 'Difficulty swallowing saliva', 'Difficulty swallowing solids', 'Weak ineffective cough' or 'Wet

sounding voice'.

or [3] Result for 'Patient airway status' is EQUAL TO 'Airway partially obstructed', 'Airway obstructed'

or 'Patent without support'

or [4] Result for 'Altered LOC/Reduced responsiveness' is EQUAL TO 'Yes'

or [5] Result for 'CN IX, X Swallowing, Gag Reflex' is EQUAL TO 'Gag reflex absent', 'Uvula

deviation (ANY)' or 'Deferred'



AND Risk of Aspiration IPOC is not already 'Active' or 'Pending'

Autonomic Dysreflexia Plan of Care –

not working

[1] Where PROBLEM EVENT is recorded as 'Autonomic Dysreflexia' (May be System generated)

AND Autonomic Dysreflexia IPOC is not already 'Active' or 'Pending'

Bladder Elimination Plan of Care [1] Result for 'Genitourinary symptoms' that is EQUAL TO 'Acute urinary retention', 'Anuria', 'Bladder

outflow obstruction', 'Burning', 'Chronic urinary retention', 'Decreased urine output', 'Dribbling',

'Dysuria', 'Frequency', 'Functional incontinence', 'Nocturia', 'Oliguria', 'Penile discharge', 'Polyuria',

'Poor stream', 'Retention', 'Stress incontinence', 'Unable to void', 'Urge incontinence', 'Urgency',

'Vaginal discharge' or 'Vulvar burning'

or [2] Result for 'Epidural line type' is EQUAL TO 'Interspinous space'

or [3] Result for 'Level of Spinal Cord injury' is EQUAL TO 'C1', 'C2'... 'C8', 'T1', 'T2' ... 'T12' (any

vertebrae response)

or [4] Result for 'Urinary Catheter' is GREATER THAN '0' (i.e. the patient has one)

AND Bladder Elimination IPOC is not already 'Active' or 'Pending'.

Bleeding Precautions Plan of Care [1] Result for 'Emesis description' that is EQUAL TO 'Coffee ground'

or [2] Result for 'INR' is GREATER THAN '3.5'

or [3] Result for 'Platelet Count' is LESS THAN '25,000'

or [4] Result for 'Prothrombin Time' is GREATER THAN '50'

or [5] Result for 'Haemoglobin' is LESS THAN '70'

or [6] Result for 'Systolic blood pressure' is LESS THAN '100'



or [7] Result for 'Heart rate monitored' is GREATER THAN '100'

or [8] Where PROBLEM EVENT is recorded as 'Hemophilia' or 'von Willebrand disease'

AND Bleeding Precautions IPOC is not already 'Active' or 'Pending'

Bowel Dysfunction Plan of Care [1] Result for (any quadrant) 'Bowel sounds, ...' that is EQUAL TO 'Absent', 'Hyperactive' or

'Hypoactive'

or [2] Result for 'GI Symptoms' is EQUAL TO 'Impaction', 'Constipation' or 'Diarrhoea'

or [3] Result for 'Passing flatus' is EQUAL TO 'No'

or [4] Result for 'Level of Spinal Cord Injury' is EQUAL TO 'C1', 'C2'... 'C8', 'T1', 'T2' ... 'T12' (any

vertebrae response)

AND Bowel Dysfunction IPOC is not already 'Active' or 'Pending'

Decreased Peripheral Perfusion Plan of

Care

[1] Result for 'Dorsalis pedis pulse, right' that is EQUAL TO 'Doppler, '0 Absent' or '1+ Thready'

or [2] Result for 'Dorsalis pedis pulse, left' is EQUAL TO 'Doppler, '0 Absent' or '1+ Thready'

or [3] Result for 'Posttibial pulse, right' is EQUAL TO 'Doppler, '0 Absent' or '1+ Thready'

or [4] Result for 'Posttibial pulse, left' is EQUAL TO 'Doppler, '0 Absent' or '1+ Thready'

or [5] Result for 'Radial pulse, right' is EQUAL TO 'Doppler, '0 Absent' or '1+ Thready'

or [6] Result for 'Radial pulse, left' is EQUAL TO 'Doppler, '0 Absent' or '1+ Thready'

or [7] Result for 'Activity assistance' is EQUAL TO 'Unable to clear secretions'

or [8] Result for (any) 'Extremity description' is EQUAL TO 'Mottled' or 'Cyanotic'

or [9] Result for 'Wound tissue type' is EQUAL TO 'Necrotic tissue, eschar' or 'Necrotic tissue,



slough'

or [10] Result for 'Capillary refill' is EQUAL TO 'Greater than 2 seconds'

or [11] Result for 'Skin temperature, upper extremities is EQUAL TO 'Cool' or 'Cold'

AND Decreased Peripheral Perfusion IPOC is not already 'Active' or 'Pending'

Difficulty Swallowing Plan of Care – not

working

[1] Result for 'Date placed NBM' that is EQUAL TO 'Yes' (a date is recorded)

or [2] Result for 'Date referred to SP' is EQUAL TO 'Yes' (a date is recorded)

or [3] Result for 'Altered LOC/reduced responsiveness' is EQUAL TO 'Yes''

or [4] Result for 'History of dysphagia/aspiration risk' is EQUAL TO 'Yes'

or [5] Result for 'Not managing saliva, drooling, wet voice' is EQUAL TO 'Yes'

or [6] Result for 'Respiration rate >30 breath/min' is EQUAL TO 'Yes'

or [7] Result for 'Recurrent chest infection' is EQUAL TO 'Yes''

or [8] Result for 'Reported coughing/choking on food or fluids' is EQUAL TO 'Yes'

or [9] Result for 'Reports difficulty swallowing' is EQUAL TO 'Yes'

or [10] Result for 'Slurred speech (dysarthria)' is EQUAL TO 'Yes'

or [11] Result for 'Suspected aspiration pneumonia' is EQUAL TO 'Yes''

or [12] Result for 'Weak voice (dysphonia)' is EQUAL TO 'Yes'

or [13] Result for 'Weak/absent volitional cough' is EQUAL TO 'Yes'

AND Difficulty Swallowing IPOC is not already 'Active' or 'Pending'



Disturbed Sleep Pattern Plan of Care –

no Paeds DTA’s

[1] Result for 'Sleeping behaviours' that is EQUAL TO 'Difficulty awakening', 'Difficulty falling asleep',

'Difficulty sleeping at night', 'Early morning awakening', 'Enuresis', 'Hypersomnia', 'Night terrors',

'Nightmares', 'Sleepwalking' or 'Reverse sleep-wake cycle'

AND Disturbed Sleep Pattern IPOC is not already 'Active' or 'Pending'

Fluid Deficit Plan of Care – Selecting

Decreased uring output also suggests

Bladder eliniation IPOC

[1] Result for 'Skin turgor general' that is EQUAL TO 'Tenting'

or [2] Result for 'Mucous membrane description' is EQUAL TO 'Ulcerated', 'Cracked', 'Dry' or 'Tear'

or [3] Result for 'Nutritional risk factors' is EQUAL TO 'Diarrhoea' or 'Vomiting'

or [4] Result for 'GI Symptoms' is EQUAL TO 'Diarrhoea' or 'Vomiting'

or [5] Result for 'Genitourinary' is EQUAL TO 'Decreased urine output'

AND Fluid Deficit IPOC is not already 'Active' or 'Pending’

Impaired Physical Mobility Plan of Care

– not working

[1] Result for 'Special orthopaedic devices' that is EQUAL TO 'Splint', 'Prosthesis', 'Brace', 'Cast' or

'Immobilizer'

or [2] Result for 'Bed Mobility assistance / Activity assistance' is EQUAL TO 'Supervision', 'Able to

assist' or 'Not able to assist'

or [3] Result for 'The patient is visually impaired' is EQUAL TO 'Yes'

AND Impaired Physical Mobility IPOC is not already 'Active' or 'Pending'

Risk of Skin Integrity Plan of Care [1] Any positive result for 'Diaper rash' or 'Skin abnormality' being charted

or [2] Waterlow score is GREATER THAN or EQUAL TO '10'



or [3] Glamorgan score is GREATER THAN or EQUAL TO '10'

or [4] Result for 'Diaper rash location' is EQUAL TO 'Bleeding', 'Blisters', 'Bright red', 'Dry',

'Erythema', 'Moist', 'P, Papules', 'Peeling', 'Pustules', 'Raised borders', 'Rash', 'Red' or 'Satellite

lesions'.

or [5] Result for 'Site 1 stage', 'Incision', 'Wound present, ulcer stage' or 'Pressure injury Waterlow' is

EQUAL TO 'Stage 1', 'Stage 2', 'Stage 3', 'Stage 4', 'Unstageable', 'Mucosal membrane' or

'Suspected deep tissue injury'

AND Location specific

AND Risk of Skin Integrity IPOC is not already 'Active' or 'Pending'

Risk for Unstable Glucose Plan of Care Order for 'Nil By Mouth' exists on the patient's current encounter

AND Location facility is Cairns Base Hospital (CBH) or LCCH

AND Person's age is <18 years

AND Risk for Unstable Glucose Plan of Care is not already 'Active' or 'Pending'

Falls Risk Plan of Care [1] Result for 'Neurological Symptoms' that is EQUAL TO 'Dizziness, Confusion/Disorientation'

or [2] Result for 'Existing incontinence/fgy/toilet assist' is EQUAL TO 'Yes'

or [3] Result for 'Orientation Assessment' is EQUAL TO 'Disoriented x 4'

or [4] Result for 'Sensory Deficit' is EQUAL TO 'Sensation/Touch deficit'

or [5] Result for 'ADLs' is EQUAL TO 'Supervision' or 'Not able to assist'

or [6] Result for 'History of Falls' is EQUAL TO 'Immediately prior to hospitalization', 'Within last

three months' or 'Within last one year'



AND Falls Risk IPOC is not already 'Active' or 'Pending'

Self Care Deficit Plan of Care Result for 'ADLs' that is EQUAL TO 'Able to Assist', 'Not Able to Assist' or 'Supervision'.

AND Self Care Deficit IPOC is not already 'Active' or 'Pending'

Suicide Risk Plan of Care – no DTA’s Result for 'Suicidal Ideation' that is EQUAL TO 'Constant' or 'Intermittent'.

AND Suicide Risk IPOC is not already 'Active' or 'Pending'



Glossary and Abbreviations

ACC Altered calling criteria - the area in ieMR Managing Deterioration view where the clincian documents modifications to vital signs

CEC Current Encounter Chart

CEWT Children’s Early Warning Tool is an early warning and response system designed to escalate care in response to recognition of deterioration of the patient.

Consult A consult order is an internal referral or request for consultation

ED Emergency Department

EWS Early Warning Signs/Managing Deterioration

FIN Financial Identification Number

FirstNet The Cerner Millennium system module for emergency medicine.

HBCIS Hospital Based Corporate Information System

HIMS Health Information Management Service

ieMR Integrated electronic medical record

Interactive View

Interactive view section of the ieMR where documentation of assessments and fluid balance occurs

Metavision The Intensive Care electronic medical system

MPTL Multi Patient Task List which lists tasks e.g. Consults

PFM Patient Flow Manager

PowerForms A form in ieMR, found in the Ad Hoc folder

PowerPlans A pre-defined set of orders which can be modified according to the patient requirements. A powerplan is generally based on a clinical pathway or best practice guidelines

PPID Positive Patient Identification

Q-ADDS Queensland - Adult Deterioration Detection System is an early warning and response system designed to escalate care in response to recognition of deterioration of the patient.

SBAR Situation, Background, Assessment, Recommendation

URN Unit Record Number – the hospital-based patient identification number assigned to a patient that uniquely identifies that patient for that hospital facility.

Widget A component which draws information from the chart to display in summary format