![Reviewing Clinical Notes – Search Result
Search result returns in alphabetical order
then reverse chronological order.
Specialty Note may be hard to delineate as almost all
visiting team uses the same note
It is mandatory for visiting team to input their team
name
They are all attached with a hashtag - #[Team Name]
If you want to filter a specific speciality, search by
Document Content #[Team Name]
For example, searching #Cardio will return all
Cardiology notes](https://image.slidesharecdn.com/iccatraining-nonicustaffv1-250718171345-9913fee8/85/ICCA-Training-Non-ICU-Staff-V1-pptx-Slides-25-320.jpg)
ICCA Training - Non ICU Staff V1.pptx Slides
- 1. Digital Critical Care Philips ICCA Training For non-ICU Staff Trust wide Version 1
- 2. Digital Critical Care • Critical care units in Royal and Aintree Hospital are using Philips ICCA for electronic patient records • Once a patient is admitted to Critical Care, all the patient’s documentation MUST be done in ICCA rather than PENS / ADT • There are a few exceptions which will be covered in the later slides Key Point: Document in ICCA under Speciality Notes whenever you document anything about a patient who is in Critical Care (Ward round, referral outcome, progress note)
- 3. Training and Access • You’ll need ICCA training and access as you join the trust, you’ll need it when you: • Review patient in Critical care • See referrals in Critical care • Want to read current and historical Critical Care notes • (Note: ICU admission and discharge summary will be sent to PENS) • To gain access: • Once you have completed this training slide, please contact IT helpdesk for access.
- 4. Scope of Training • You will learn how to: • Log on and off • Basic navigation • Review patients’ obs charts, drug charts, case notes • Write in patients’ notes • We will also cover: • What stays in the current trust EPR system
- 5. Logging On & Off
- 6. Logging On & Off On your desktop: 1. Double click on ICCA icon If there is no icon, find a cloud PC or log in via remote cloud access 2. Enter your Username & Password This is the same as ADT Dashboard 3. Choose the correct domain If not defaulted to your site
- 7. Once you log in, you will see this Census board It should show you the patient list of your base ICU You will also see: 1. Top menus 2. Various Critical Care units on the left To Log off: Click on the x button on the top right. Census Board
- 9. Home Menu Click ‘Find Patient…’ to search for: • Admitted patient – Easier if you search in the unit where the patient is currently in • Discharged patient – Useful when you received a step-down patient Click ‘Text Size’ to adjust font sizes You can also split the screen by: ‘Vertical Split’ or ‘Horizontal Split’ Please do not use the rest of the buttons
- 10. Census Menu Please do not use any of the buttons here All bed movement is handled in Whiteboard Using these buttons will break the patient flow.
- 11. XLinks Menu These are the various links to our commonly used systems or website
- 12. Selecting a Unit: Admitted Pts 1. The system should automatically log you into the unit where you are based. Otherwise, pick a unit on the left. 2. It will show Admitted Patients by default 3. You can see patients’ details: • Bedspace • Name • Hospital Number • Date of Birth • Age • Gender • Speciality • Length of stay • Level of care • Step down readiness • IPC concerns • Trial(s) enrolled
- 13. Selecting a Unit: Discharge Pts Clicking on the Discharged Patients will show all discharged patients in the last 30 days
- 14. Adding a Patient to ‘My Patients’ list In Admitted Pt board, Right click on a patient to ‘Add to My Patients List’ This is helpful if you are reviewing a patient regularly Your saved list is on the top left of the blue panel called ‘My Patients’ Please do not Transfer, Discharge or Move/Swap
- 16. Opening a Patient’s note Double click on patient’s name to open a note The default view will be the patient’s Observation chart
- 17. Reviewing Patient There are generally 3 main document types to review: 1.Observation charts 2.Clinical Notes 3.Drug chart
- 18. Reviewing Observation Charts The system shows Clinician Overview and Continuous Drug Infusions by default. Clicking on another tab will ‘stack on’ to the currently opened tab. Example in this is the Clinician Overview Graph Double clicking on a tab will show only the tab and hide the rest
- 19. Reviewing Observation Charts Right clicking on the timeline above the chart will enable you to: 1. Adjust the interval of the observation shown 2. Go to a specific date
- 20. Reviewing Observation Charts Abnormal parameters will be highlighted in yellow
- 21. Reviewing Clinical Notes Section Contains Overview Clinical Summary and Patient Profile – At a glance clinical information about patient Charts Observation Charts Lab Test Common lab results Radiology Radiology reports Microbiology All microbiology information during this admission goes here Medications Drug charts Clinical Notes All clinical notes go here – Most relevant section to visiting team Nursing Notes Risk assessment, Daily Management and Care plans AHP Notes Physio, OT, SALT, Dietitian, Clinical psychology notes Procedures Procedures notes – excluding IR procedures and operation notes (in PENS) Communications Patient or family discussion documentation Escalation Plan Documentation of limitation of treatment. CPR status is in ADT Dashboard Research Research Notes Audit ICU use only Discharge Discharge summaries Word Report ICU use only Imported Documents Limited imported documents relevant to ICU stay
- 22. Reviewing Clinical Notes – Clinical Summary Under Overview > Clinical Summary This document aggregates all the relevant clinical information to give you a picture of patient’s background, clinical course, latest ward round issues & plan. It also display the latest relevant vitals sign
- 23. Reviewing Clinical Notes – Clinical Notes ICCA displays clinical notes by date Notes are arranged in reverse chronological order Click through the notes one by one to see its content This is different from PENS where you scroll through a timeline Generally, there are: • Daily Ward Round – One per day • ICU Notes – Any free text entries by ICU staff • Speciality Notes – Any free text entries by non-ICU staff
- 24. Reviewing Clinical Notes – Search There is a Search function if you are looking for something specifically Shortcut Key Ctrl + F You can search for a document by: • Document Title – The name of the form (or part of) • Document Type • Date Range • Document Content • User Name
- 25. Reviewing Clinical Notes – Search Result Search result returns in alphabetical order then reverse chronological order. Specialty Note may be hard to delineate as almost all visiting team uses the same note It is mandatory for visiting team to input their team name They are all attached with a hashtag - #[Team Name] If you want to filter a specific speciality, search by Document Content #[Team Name] For example, searching #Cardio will return all Cardiology notes
- 26. Under Medication section, the most relevant ones are: • Drug Chart • Medications Overview • Medicines Reconciliation Non-ICU staff can view the drug chart but cannot prescribe Please speak to ICU staff for any prescription advice Reviewing Drug Chart
- 27. Reviewing Drug Chart There are 4 main types of drugs by frequency: • Scheduled (Regular) • One Time (Stat) • PRN (As required) • Continuous Legend: • Ticked boxed – Administered • Unticked boxed – Due / Overdue • Half-shaded red box - Held
- 29. Writing Clinical Notes There are only 2 forms that non-ICU staff document in (Unless otherwise pre-arranged): 1. Speciality Notes 2. Speciality Notes (with ICU Summary)
- 30. Writing Clinical Notes – Add Document On the top left corner, click Add Document All available documents are listed by default Search for Speciality… under the Filter field Speciality Note & Speciality Note (With ICU Summary) will appear Double click on the document you wish to create Then click OK
- 31. Writing Clinical Notes – Types of Speciality Notes Speciality Note This is the same as free text note in PENS You must pick your Speciality / Team from the list This is suitable for: Ward round, ad hoc quick documentation Speciality Note (with ICU Summary) This is the same as Speciality Note except with pre-populated information about patient This is suitable for: Referral review, specialist nurse review
- 32. Writing Clinical Notes – Types of content Green text is content carried from previous note • You need to click on it to verify it if you want to keep the content • If you don’t verify it, it will disappear when you save the form. Pink text is unsaved content Black text is saved content Please don’t edit the content of ICU Summary Click through the content to turn Green text to Pink Choose your Speciality / Team Enter your name, role and contact number Type your note Save note (see next slide)
- 33. Saving Clinical Notes The Save Chart button will only be active when you click away from the content field The quickest way would be to click on those area on the left (shaded pink area in this screenshot only) Saved content will now be black Note that the content from Diagnosis has disappeared because I did not verify it You can also save note by using shortcut key Ctrl + S On the top left corner, click Save Chart You will be prompted to enter your username and password
- 34. Editing Clinical Notes Previous version Current version There is an audit trail for note edit If a note content has been changed, a clock icon will appear on the right To look at the edit history, right click and click Properties You can see the historical version below the current versions
- 35. Deleting Clinical Notes If you have made an error and would like to delete your note Find your notes on the left under Clinical Notes Double check that this is the correct note you want to delete Right click on it Click Discontinue The discontinued note will have a strike through it Other users can choose to hide discontinued to make it invisible
- 36. Components remaining in Trust system Several trust level documents remains as they are The following is a non-exhaustive list: • DNAR • Consent Form 1 • Consent Form 4 • Capacity Assessment • DOLS • VTE Assessment • Operation notes • Theatre pathway
- 37. Team Specific Workflow Please visit http://luhft.icu/dcc-team for further information relevant to your team / role / department. If otherwise not listed in the page, then please use: • Speciality Note or • Speciality Note (With ICU Summary).
- 38. End of Training • Please contact IT helpdesk for access if not already given during induction after training completion. • ICCA is accessible in all cloud PC • If you use non cloud PC in your office or laptop, please go to Start > Software center and install ICCA Thank You!