Knowledge base » Visit forms
-
1.0 How to attend an appointment and create a visit
On Appointment Management, once the patient has been admitted, tick the box in the Attended column A popup will appear asking 'Are you sure you wish to confirm the appointment and create a patient visit?' Click Ok 'New Visit' will open, showing a list of past visits and displaying the current visit with forms for completion ...
-
2.0 Accessing Visit Forms
Once an appointment has been attended, a visit is created in the patient record. The visit reason and visit type dictate which forms will display. Click on the name of a form to open it and record information about this visit ...
-
3.0 Flow Chart
The Flow Chart can be accessed via an icon from most clinical patient's pages. The icon is a lady with purple shirt and hair, called Aunty Flo ...
-
4.0 Risk Assessment - Nursing
The Risk Assessment (Nursing) has four sections: Pressure Risk assessment VTE risk Infection status Delirium and cognitive impairment assessment (4AT score) The pressure risk assessment has 7 assessments with 4 options in each. They create a total Norton Pressure Risk Score and a Pressure risk...
-
5.0 Visit Notes entry
Viewing and recording Visit Notes After attending the appointment for your patient, to enter and view integrated notes, click on the Visit Record form ...
-
6.0 Nursing Assessment - Observations - Where to record observations (Nursing assessment, obs quick link from appointments)
From the Visit page on today's visit, click the Nursing Assessment form ...
-
6.1 Nursing Assessment - entering Neuro observations
Neurological observations display on the Nursing Assessment as collapsed by default unless the patient requires neuro obs to be recorded, following which the section stays expanded. To access the neuro obs fields, tick 'Show Neuro observations' ...
-
6.2 Nursing Assessment - entering glucometer readings
Under the Observations grids, there is a field for entry of glucometer results. ...
-
6.3 Nursing Assessment - Clinical alerts and Key Comorbidities
A clinical alert can be set on the Nursing Assessment that will display on the Flow Chart. This is carried forward to future visits unless it is deleted. ...
-
6.4 Nursing Assessment - Side effects
Under the initial assessment heading, record the patient's mental state/well being and the level of distress they're experiencing. For recent side effects, briefly record the most significant toxicities but all side effects should be recorded with grading on the Visit Record ...
-
6.5 Nursing Assessment - Falls Risk
The Falls risk should be recorded on the Nursing Assessment, including if the patient requires assistance to walk and if they use any aids such as a walking stick. When the patient returns for another visit, 'Copy from previous' can be ticked and will retrieve the previous entry which can be saved or added to respectively. ...
-
6.6 Nursing Assessment - Skin Integrity
In the section on skin integrity, fields display depending on which selection is made If the skin integrity has previously been recorded, 'Copy skin integrity from previous' tick box will become active, allowing the user to populate the fields that were entered at the last visit. These can then be modified if needed before saving. ...
-
6.7 Nursing Assessment - Access Types
To record information about the type of access used for treatment, go to the Nursing Assessment and scroll down to 'Access Types' ...
-
6.8 Nursing Assessment - Outcome and Discharge
When the patient's treatment is complete, the bottom section of the Nursing Assessment can be filled in. The Treatment outcome comments will display in the Visit Notes on Visit Record as well as on the Flow Chart for quick review of the last treatment administered ...
-
7.1 Drug Administration - How to find the green syringe
To find the drug administration page; attend the appointment for the patient Click on the visit form, Protocol Cycles On the cycle that matches today's date, click on the green syringe on the far right side of the protocol cycle line Drug administration will open If there is...
-
7.2 Drug Administration - How to get the most recent weight to display
When Drug Administration is first opened, there will be no current weight displaying. You are required to retrieve the weight by clicking the 'Weight' hyperlink that will take you to the Visit Record. ...
-
7.3 Drug Administration - How to sign for drugs
.To sign that medications and patient identification have been checked, scroll down to the list of medications for administration today. Tick the Sign box if you are the intended administrator of the drug, or Co-sign if you are the nurse checking the medication and patient ID ...
-
7.4 Drug Administration - How to enter the time/date of administration
There are two ways to enter the start and end time for the medication administration. 1. Click the green 'start' button to stamp the current time in the time field 2. Manually enter the time using a 24-hour clock, e.g. 1430 will display as 14:30 PM ...
-
7.5 Drug Administration - How to edit the actual dose able to be administered
Sometimes it will be necessary to change the dose you're able to administer, either due to an infusion reaction, patient refusal, non-arrival of the drug etc. In this case, you'll need to edit the actual dose on Drug Administration. First open Drug Admin Find the drug that you are unable to administer or that you're only able to give a partial dose of. ...
-
7.6 Drug Administration - How to enter Admin Notes
To enter notes about the administration of medication on a protocol, click on the edit pencil to the right of the drug line on Drug Administration. You will have options to choose 'canned text' (pre-formatting commonly used phrases) or to 'Edit' by manually entering text regarding that medication's administration. Selecting 'canned text' will ...
-
7.7 Drug Administration - How to add a drug - nurse-initiated, standing orders, phone orders
To add a medication to the drug chart, click the plus + sign at the top of the list of medications ...
-
7.8 Drug Administration - Why hasn't the prescribed dose calculated an actual dose?
When you open Drug Administration, any doses that require a height, weight and BSA to calculate, will not show an actual dose to administer. To get the dose to calculate, click on 'Weight' at the top of the drug chart. This is a hyperlink to Visit Record where the weight can be saved. ...
-
7.9 Drug Administration - How to enter a Se creatinine manually
On Drug Administration, pathology tests are usually imported electronically into the Clinical Summary at the top of the page. In some cases, you may need to manually add a Se creatinine for calculating a dose. In this circumstance, in the Clinical Summary, click on Se creatinine in blue font. It is a hyperlink so will open a popup window. The screenshot below...
-
7.10 How to enter an eGFR manually
In most cases, an eGFR will display in the Clinical Summary if pathology results have imported to the patient's record. If for some reason the eGFR is absent, the user can manually enter a known eGFR or a Se creatinine into the Summary on Edit Protocol or Drug Administration. On the Clinical Summary, click eGFR which displays in dark blue to show it's a hyperlink to open a popup. ...
-
7.11 How to enter a baseline GFR
In order to receive an alert if the eGFR has changed more than 20%, it's necessary to enter a baseline eGFR value for comparison. This can be done from the Clinical Summary on Edit Protocol or on Drug Administration via two different links. The first is by clicking eGFR and then clicking 'Add' (See tutorial 7.10 How to enter an eGFR manually) Once the...
-
7.12 Why hasn't the Carbo dose calculated
For a dose of carboplatin to calculate, it requires a height, weight, recent se creatinine or eGFR to be available in EpiSoft. If any of these parameters are missing, the Actual Dose field will be blank and a yellow alert triangle will display. Click on the triangle to see the reason why the dose hasn't calculated: ...
-
7.13 How to view the formulas used to calculate doses
Every calculating prescribed dose will have a corresponding formula able to be viewed on Edit Protocol and Drug Administration. To see the formula for a particular drug, click on the 'fx' symbol on the drug line. This example shows the formula used for 'mg/m2': ...
-
8.0 ADDIKD - Anti-cancer drug dosing in kidney dysfunction - Carboplatin dosing
Carboplatin dosing: There are three choices of units for Carboplatin dosing that all use the Calvert equation, but each use a different method to calculate kidney function: ...
-
8.1 ADDIKD guidance to kidney function measurement - The Clinical Summary
Clinical Summary: The Clinical Summary follows eviQ guidelines regarding estimation of kidney function in anti-cancer drug dosing. There are sections on the Clinical Summary for kidney function results and for system calculation of results where that result is not available to be imported. ...
-
8.2 ADDIKD guidance to kidney function measurement - Se creatinine, eGFR, baseline eGFR
Se creatinine: This hyperlink opens a popup window that allows manual entry of a Se creatinine value if no result has imported electronically. If there is no eGFR available but a Serum creatinine is, the system will calculate an eGFR automatically from the Se Creatinine. eGFR: The eGFR result can be clicked to open an interim popup that displays the previous 20 results, either imported, manually entered or system calculated. ...
-
8.3 ADDIKD guidance to kidney function measurement - Fx icon function to show the equation used to calculate the dose
Fx icon Wherever a calculation is required to generate a prescribed dose, an f(x) icon will display. To see the patient parameters in the equation, click the f(x) icon. ...
-
9.0 Record Summary
In the patient record is a summary of the main pages in the record called the Record Summary. Each heading is a hyperlink to the relevant page but the data on Record Summary itself is read-only. At the top of Record Summary are the patient's name, DOB, contact details, NOK and their Principal doctor: ...
-
10.0 Medication Record
The medication record form is where non protocol medications are added. The form functions as both a medication record and a prescription writing module. Add a medication Click on 'Record a medication' to expand the popup: ...
-
11.0 Edit Protocol
Edit Protocol can be accessed from Protocol Cycles by clicking on the name of the cycle. This is where treatment can be prescribed. ...
-
11.1 Edit Protocol - Editing Medications in Episoft
Where to find Edit Medication: 1. Medications can be edited from Protocol Cycles 2. Click on the name of the cycle to open Edit Medication 3. Scroll down to the medication to be edited 4. Click on the pencil ‘tooltip’ to the left...
-
11.3 Substituting a medication on Edit Protocol
A drug on Edit Protocol can be substituted for a different strength, form or route, or to a different medication First, click the pen tool to the left of the medication name to edit the dose. On the left of the Edit Medication popup window is an icon to substitute the drug. Click the icon to open the MIMS lookup to choose the version you prefer or to...
-
Admission Coding form
The admission coding form is where the condition code, procedure code and DRG for the admission is recorded. This form cannot be completed until the patient has been formally discharged. The section highlighted in the red box will be read only until the patient has been discharged. Click here to learn how to discharge a patient. Once you have completed the form set the radio button to 'Coding complete,...coding, drg, training module
-
CODING: The reason why coding must be done before submission of inpatient billing
Inpatient billings for the hospital portion requires clinical coding or the IHC (inpatient hospital claim) will be rejected. If you submit a paper claim, you set a provisional diagnosis and provisional procedure on the HC21 (national claim form) but you don’t need a DRG, then you have to do the formal final coding before submitting your mandatory Hospital Casemix Protocol data which includes all diagnoses, procedures and DRG....
-
Cancer Visit Record Form
Below is the top half of the ‘Cancer Visit Record’ form. When a patient has arrived for a scheduled appointment, it is essential to carefully complete the 'Visit Record Form'. This is because some of the questions and answers can directly impact a patient by altering protocol requirements such as 'Medication Dose'. Functions of this...weight, visit notes, ecog, symptoms, toxicities, bsa
-
Cancer Assessment & History Form
This form is used to record the patients primary diagnosis (which is copied to the conditions & allergies form). Duration of disease, date of diagnosis, method of diagnosis. Family history and personal history of cancer. If the patient has had previous cancer treatment cancer treatment history grid will appear where details of previous treatment can be recorded. The following section is where social and lifestyle factors are recorded. For patients that have or currently smoke there...tnm score, primary diagnosis
-
Patient Education Checklist
This form is used to record what information has been provided to the patient and by whom. At the top of the page a treatment summary is displayed with information on the current protocols, the cycle the patient is on, last treatment and next treatment date and any allergies. The check list section is where users check off the education they have provided to the patient. The form uses role based privileges to determine which boxes you are allowed to check. I am logged in as a nurse so the...
-
Medication Record Form
The medication record form is where non protocol medications are added. The form functions as both a medication record and a prescription writing module. To add a new medication click on the green ‘+’ icon on the top of the grid. The grid will expand out to reveal the red lookup button. There is a ‘drug not found’ checkbox which can be used for drugs that are not listed on MIMS. If drugs are entered using ‘drug not found’ it is not possible to report or interrogate this data. Click on...medications, prescription, ad hoc medications
-
Conditions & Allergies Form
This form uses lookups to ICD10AM and SNOMED-CT to record and code conditions and allergies. To add a condition click on the green ‘+’ icon on the top of the grid. The grid will expand out to reveal a red lookup button. If after searching for the condition using the lookup you cannot find it you may check the ’condition not found’ checkbox. This will allow you to free text in the condition. This should only be used as a last resort. Conditions that are added without coding cannot be...
-
Protocol Module (EpiSteme) - Protocol Cycles Page
The protocol module is where protocol treatments are recorded prescribed and ceased on a patient record. The module has a number of pages, the first page you land on after clicking through from 'Episteme (treatment via protocol)' on the Visit Details page is the ’Patient protocol cycles’ page. This page displays the patient future, current and past protocol information. The first section shows the list of current and upcoming protocol cycles prescribed to the patient. Active...
-
Protocol Module (EpiSteme) - Drug administration page
To access the 'Drug Administration Chart' first click on the 'EpiSteme Treatment Via Protocol' visit form Then click on the green syringe icon as seen below. This is the top half of the Drug Administration page. It displays information on the cycle, a...
-
Protocol Module (EpiSteme) Adding scalp cooling to a patients protocol - Interactive tutorial
This tutorial shows you how to add scalp cooling to a patients protocol and where that displays in booking requests and on the appointment management list Click on the link to access the tutorials http://ior.ad/pkJ ...
-
Observation Graphs
The observation graphs can be accessed either through the 'Drug Administration' page, the 'Nursing Assessment' form small grey and green icon on the top of the observation grid. It can also be accessed by clicking on green quick link at the top of some pages like record summary or visit details page....
-
Video Tutorial- Patient Education Checklist
How to find and complete the Patient Education Checklist for a new patient or a patient starting on a new protocol http://www.screencast.com/t/1OZWKdVWVP6G ...
-
Video Tutorial- Drug Administration
How to navigate to the Drug Administration page and administer and sign for a medication http://www.screencast.com/t/rSKCoCilv ...
-
Video Tutorial- Nursing Assessment Form
How to navigate to the Nursing Assessment form and how to complete it. http://www.screencast.com/t/KsIjuMwgqW ...
