Nursing charts

Each admitted patient's chart (Doctor orders & nursing add-on): the doctor's orders with dose, route and how often, the medicine round with each dose given, held or refused, vitals with the signs out of range flagged, intake and output with the 24-hour balance, and nursing notes. Every entry carries who wrote it and when and never changes. Open only to roles with "Can open patient records".

Steps

  1. Open Nursing charts and press Open a chart. Pick the patient's bed (the IP number, name and doctor fill in) or type them, add any allergies, and open it.
  2. On the Orders tab press New order. For a medicine give the dose, the route and how often; the times follow (twice a day is 08:00 and 20:00). Diet, investigations, procedures and nursing care are orders too. Press Stop when the doctor stops one.
  3. On the Medicine round tab mark each dose Given, or Held or Refused with the reason. Overdue doses (an hour past) are shown in red; medicines given when needed have Give now.
  4. Record vitals, intake and output and notes on their tabs. The ward list shows each patient's overdue doses, the signs out of range and how long since the last vitals.

Tips

  • Entries are never edited or deleted: write a new note to correct one. Close the chart when the patient goes home; a closed chart takes no more entries.
  • Flagged signs: temperature 38 °C or more or under 36, pulse over 110 or under 50, breathing over 24 or under 10, oxygen under 92%, systolic under 90 or over 180, pain 7 or more.
  • Switch on "Can open patient records" for the nurses' and doctors' role in Users → RBAC. Each chart's reads and changes go to the patient's access log, and StartAI never reads the charts.

In the app, press F1 or ? on this screen to open this guide next to your work.

This guide belongs to the Doctor orders & nursing module. Learn more

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