For each of the following sections of the screen, enter the appropriate information. Click Save (upper right corner) at any time to save your work. If you navigate away from the page without saving, you will be prompted with a message and your entries could be lost.
Triage Level:
In the Level field, use the drop-down list to select the appropriate level of care required for this patient.
The current date/time defaults in the Date and Time fields. Use the calendar and clock icons to modify the date, and/or time, if desired.
Provider:
In the Provider Notified Date and Time fields, use the widgets to select the date and time that the provider was notified that the patient was in the Emergency Department.
In the Provider Arrival Date and Time fields, use the widgets to select the date and time that the provider arrived to the Emergency Department.
Chief Complaint:
In the Episode of Care field, select Initial Patient Assessment or Follow-up Visit. (Note: SNOMED codes are associated with the selection made in this field - Initial Patient Assessment: 315639002 and Follow-Up Visit: 185389009 - and is displayed on the CCD documents.)
In the Patient Last Known Well fields, enter the date and time when the patient was last known to be well. (Note: These fields are used for Meaningful Use calculations and reporting.)
In the Stated Complaint field, enter the problem as the patient or patient representative has described it.
In the Historian field, select the person from whom you received the Stated Complaint information (usually the patient or a patient representative).
Select the appropriate Body System and Complaint from the available options based on the clinician’s observation and the patient’s stated complaint. These two fields are interdependent - the Body System you choose determines the available Complaint list. To enter additional complaints, click + Add Complaint. An additional set of Body System and Complaint fields are displayed.
To remove additional complaints that have been added, click Remove. This option is only available for added complaint fields. The original chief complaint fields must remain on the screen.
Treatment Prior to Arrival:
In the Arrival Mode field, select the appropriate mode of arrival to the ED. Then, check all the treatment options that the patient received on the way to the ED. (Options include ASA, Backboard, C-Collar, etc.)
Some of the selections may trigger pop-up boxes requiring additional information regarding the treatment. For example, if you select ASA, Morphine, or NTG, a Triage Medication Dosage box is displayed requiring Route and Dose information. In addition, if you select O2, a Triage O2 box is displayed requiring Delivery Device and Amount information. For these pop-up boxes, select the appropriate responses and click Save. You are returned to the Triage page and the selected information is displayed next to the treatment. (If you wish to modify the selected information, click Edit. The pop-up box is displayed allowing you to make changes. Remember to click Save to return to the Triage page.)
Immediate Treatment:
In the Treatment field, select the treatment(s) given immediately to the patient.
In the Treatment Outcome field, select the outcome of the treatment in the ED from the following options:
Patient Refused Treatment
Patient Was Refused Treatment
Patient Was Stabilized Then Hospitalized
This field is reported on the Patient Log Report, which is accessed on the Reports page.
Next to the ”bed” icon, select an ED bed (or Waiting Room) for the patient.
And, if necessary, click Order Entry to place orders for this patient. (See the Create Order section for details on entering orders for this patient.)
Allergies:
If applicable, check the No Known Allergies or Allergies Not Assessed check boxes.
Or, begin typing the allergy in the Allergy look-up field. As you type, matches to your typed text are displayed in two categories: Hospital List and MediSpan List (The two categories are displayed in the drop-down. However, you may need to scroll down to view both lists). Click the allergy to select it.
If you don't see the allergy you are looking for, you can type it directly in the Allergy look-up field. However, it is important to note that free-text allergies are NOT included in interaction checking. Click here for more information regarding interaction checking.
Then, click Add to add it to the patient's list. The Allergy Severity box is displayed.
In the
Severity field, use the drop-down
list to select the appropriate severity of the reaction. Check any
Associated Symptoms that apply and click Save.
You are returned to the Triage page and the allergy, the selected
severity, and the associated symptoms are displayed.
If you wish to modify the selected information, click Edit.
The Allergy Severity box is displayed allowing you to make changes.
Remember to click Save to
return to the Triage page.
If the allergy that you enter interacts with existing medication orders, you will receive a warning message. See the Alerts section for more information.
Repeat steps A & B to select additional patient allergies.
In the Allergy band placed on patient field, select Yes or No.
Pain Assessments:
In the Body System field, select the location of the patient’s current pain.
In the Numerical Pain Scale field, select the intensity of the pain as indicated by the patient. (If you would like to use a different pain scale, see Step E.)
In the Location field, type the location of the patient’s pain.
In the Duration field, type the quantity in the first field and then select the appropriate interval/frequency in the second field, e.g. 3 days.
If you would like to use an additional pain scale, click Use next to the Wong Baker Faces Pain Scale or the FLACC Pain Scale.
Wong Baker Faces Pain Scale: Select the appropriate face indicated by the patient and click Save. The appropriate value is displayed in the Numerical Pain Scale field.
FLACC Pain Scale: Choose the correct option in each of the Face, Leg, Activity, Cry, and Consolability rows and click Save. The appropriate value is displayed in the Numerical Pain Scale field.
To add additional pain locations, click Add More and repeat steps A-E.
Click Save (in the top right corner) to save the information and return to the Dashboard. If you wish to return the Dashboard without saving, click Back to Main.
When saving, if required information is missing, it will not return you to the Dashboard and a message will appear in red next to the applicable field indicating the missing information.