Document Peritoneal Dialysis Nursing Visits
1. Introduction
This tutorial explains how to document a Peritoneal Dialysis nursing visit accurately. You will learn to navigate the system and complete all necessary documentation steps for patient care.
2. Select Peritoneal Dialysis
Select your patient and Click Peritoneal Dialysis.
3. Open Nursing Visit Section
Click Nursing Visit.
4. Add New Nursing Visit
Click Add New Nursing Visit.
5. Select Sections
Notice the buttons along the top. You can choose any button and hover over some to view and go to those sections.
6. Expand Sections
Notice the plus sign within some sections. You can click to expand and view or chart different areas.
7. Expand Plus Signs
In this section it is a review of the PD Order.
8. Choose Visit Type
Within this area, you have different options for your nursing visit.
9. Select Monthly Visit
If you choose Monthly visit, it expands or opens other selection of options.
10. Fill Visit Details
Notice the different sections.
11. Monthly Visit Expanded
Or you can also mark that this is a support services visit or perhaps a telehealth visit.
12. Patient Assessment Section
Here is the patient assessment section, if filled out, this will flow to the dialysis visit note for the physician, so they can view that information as well.
13. Enter Notes in Sections
Notice that some sections have notes; here is where you can enter notes for that particular section.
14. Access Transfer Set Placement Date
This transfer set placement date crosses from the PD Catheter documentation section.
15. Enter Replacement Date
When entering the replaced-on date and clicking update; it will automatically update to the next 6 months. This can also be manually adjusted. You will also see a history listed below.
16. Document Examination Areas
Under the examination section, you can document different areas.
17. Respond to Examination Prompts
Depending on the question. Here, in this example, if you say yes, it will open additional options for you to either add notes or select a drop-down option.
18. Access Examination Section
Here you can see the Discharge and Tenderness sections for the PD Catheter Exit Site Examination.
19. Review PD Fluid Exam Section
Click the plus sign to expand and document on the PD fluid examination section.
20. Select Yes or No Option
Select yes or no to indicate the presence of specific examination findings.
21. Choose Additional PD Fluid Appearance
Choose the appearance of the PD fluid from options like clear, cloudy, blood tinged, or other.
22. Choose Additional PD Fluid Appearance
Complete the additional sections using the available drop-down options.
23. Access Cardiac Examination
Click here to proceed to the cardiac examination section.
24. Access Lung and Edema Sections
Complete and fill out any notes related to the Cardiac section.
25. Access Lung and Edema Sections
Click here to expand and access the lungs, Neuro, and edema sections as well.
26. Medication Reviewed
The medications reviewed is simply stating that you've reviewed the dialysis medications.
27. Review Medications
To document monthly med reviews, you will need to go to the Home Medications section.
28. Foot Exams
In Some areas, like the foot examination or pain level, if you answer yes, it will expand or open another section.
29. Click to enter details
This foot exam section, when yes is selected, you can answer if the patient is diabetic and click the document details button to open and document the detailed information.
30. Hover for Medication Info
In the Medication section. If you hover over a medication dose amount, a pop up may display telling you the last time it was given. Hovering over the yellow plus symbol will display notes added from the order.
31. Click on the Dose Detail option
To document the amount of medication you have given. Click on the Dose Detail option, this looks similar to a pad and pencil. Hovering may also display a Suggested amount.
32. Document Medication Dose
To document dose details, mark how many of each vial are you using to total, in this example, 80 micrograms.
33. Select Dose Amount
In this case, we're using two of the forty-microgram vials. Enter 2 in the count section And Click Save
34. Enter Time Given & Save Medication Entry
Enter the time you gave the medication. Reminder: F2 will enter the current time. Click Given By and enter your credentials. Don't forget to Save often.
35. Navigate to Medication Reason
If a medication is NOT given during the Visit. Click Reason med not given drop down and select appropriate option if not giving a medication.
36. Select Vaccine
To document vaccines, it is a similar workflow as the medications. If the vaccine series is completed click on the Done box.
37. Given By or Next Due Date
Mark the Given By and enter your PIN or password to sign off if you marked the Vaccine as given. Enter the next due date if the series is not completed.
38. Open Medication Dispensed
Click on Meds Dispensed drop down to document any medications you are providing the patient for at home use
39. Fill Medication Type
Select the appropriate Dispensed amount days.
40. Enter Quantity Given
Enter the amount given. 60 pills for example.
41. Click Save
Click Save to save the entry.
42. Click Save
Click Add New to add another entry.
43. Open Labs Drawn Section
Click Labs Drawn, if drawing labs.
44. Select Monthly Labs Drawn
A new window will pop up. Click on the appropriate Labs Drawn option, for example monthly Labs. Enter the Pre and Post draw times.
45. Fill Labs Drawn Date
Choose the appropriate name from Labs Drawn By dropdown.
46. Click Sign & Save
Click Sign and Save and Click Close.
47. Add Additional Notes
Enter any additional notes here.
48. Sign and Update Record
Click here to Sign and Save.
49. Approve and Lock Record
Click Approve and Lock to complete the Visit. If any required items are missing, you will be informed by a pop-up box. If needed, Complete the required items, Sign and save and Approve and Lock. Repeat process as needed.
