Transcription
NURSINGUSER MANUALVersion 4.0April 1997(Revised January 2000)Department of Veterans AffairsTechnical ServiceClinical Applications Product Line
PrefaceNursing is a component of the Department of Veterans Affairs VISTA (Veterans HealthInformation Systems and Technology Architecture) program. It comprises software which isused to:1) Plan and document nursing care provided to the veteran patient.2) Support nursing administration by providing data/information for nursing organizationaldecision-making purposes.3) Provide and summarize data for performance improvement.4) Provide aggregate data/information for nursing research endeavors.5) Support nurse educators by providing data/information for the tracking of mandatoryprograms and staff education.The Nursing Focus Group and nursing application developers designed this manual to explainthe functionality of the package to the nursing application coordinator(s), provide information toresolve any operational issues and elucidate the flexibility of the software package. This manualcan also be used as reference to assist IRMS (Information Resource Management Service) staffin the technical support of the application.April 1997Nursing V. 4.0 User Manuali
PrefaceiiNursing V. 4.0 User ManualApril 1997
Table of ContentsSection 1 Package ManagementIntroduction .1Chapter 1 Implementation and Maintenance .1.1Virgin Installation of software .1.1Non-Virgin Installation of software .1.15Site Configurable Files/Fields.1.15Site Configurable Output .1.17Resource Requirements .1.17Technical Errors .1.18Chapter 2 Maintenance of Administrative Site Files .2.1Administrative Site File Functions .2.1AMIS 1106 Acuity Edit .2.3Privilege File Edit .2.6Certification File, Edit .2.8FTEE Service Budget (1106b) File, Edit .2.10Load Grade/Step Codes .2.14Nursing Location File, Edit.2.16Print Existing Location File Entries .2.26Service Position File, Edit.2.32Tour of Duty File, Edit.2.36Vacancy Reason File Edit .2.38Site Parameter File .2.40Clinical Background File, Edit .2.45Product Line File Edit .2.47Chapter 3 Maintenance of Clinical Site Files .3.1Clinical Site File Functions .3.1Standard Patient Plan of Care, Print .3.2Patient Plan of Care, Site Configuration .3.19Ward Activation Patient Update .3.32Ward Deactivation Patient Update.3.34Selected V/M Site File Functions .3.36Enter/Edit Vitals Qualifiers.3.38Change Default Qualifiers for Temp./Pulse.3.41Display Vitals Category/Qualifier/Synonym Table .3.43Configure I/O Files (ADP Coordinator Only) .3.46Intake Type .3.48Output Type .3.50Output Subtype .3.52Intake Items .3.54IV Site .3.56IV Solution .3.58Shift Starting Hour and Other Parameters .3.60IV Site Description .3.62IV Catheter .3.64April 1997Nursing V. 4.0 User Manualiii
PrefaceIV DC’ed Reason .3.66Chapter 4 Special Functions .4.1Special Functions .4.1Admit/Transfer Pt. (Nursing Pkg. Only).4.3Inactivate/Disch. Pt. (Nursing Pkg. Only) .4.5Employee Activation/Separation Report .4.7Manual Nursing Acuity/Separation Run .4.9Unclassified AMIS 1106 Patients . 4.11Manhours Exception Print by Service .4.13Unclassified Midnight Patients .4.15Manhours Exception Print by Location .4.17Position Control/Staff File Integrity Report . 4.19Chapter 5 Warnings and Messages .5.1Classification Warning Message.5.1Patient Not Admitted Due to Invalid MAS Ward .5.3Patient Not Admitted With MAS .5.4Patient Is Not Active In the Nursing System .5.5Incomplete User/Person Data .5.6Incomplete Nursing Data .5.7Incomplete Service Position Data .5.8Nursing Alerts .5.9Chapter 6 IRMS Options .6.1NURS Staff Experience Integrity Check/Fix.6.1Classification File Purge .6.3Chapter 7 Maintenance of Performance Improvement Site Files .7.1QI Site Files .7.1QI Summary Standards of Care/Practice File .7.2QI Summary Frequency File.7.4QI Summary Rationale File .7.6Section 2 AdministrationChapter 1 Package Operation.1.1Chapter 2 Staff Record.2.1Staff Record Edit.2.1Demographic Data .2.4Personnel Data .2.9Status and Position .2.11License .2.20Probationary Period/Promotion .2.22Annual Review/NPSB .2.24Professional Education.2.26Professional Experience .2.28ivNursing V. 4.0 User ManualApril 1997
Table of ContentsNational Certification.2.30Military Status.2.32Edit All Employee Data .2.35Location Edit, Employee .2.36Staff Record Report .2.38Individual Staff Position/Location .2.44Chapter 3 Administration Reports .3.1Administrative Reports .3.1Academic Degree Reports .3.5Age Reports .3.18Certification Reports .3.30Gender Reports .3.39Grade Reports .3.54License Reports .3.70Military Reports .3.76NPSB Reports .3.90Nursing Degree Reports .3.94Proficiency Reports .3.107Comb. Acad./Nurs. Degree Reports .3.110Salary Reports .3.115Salary Report For Entire Service .3.117Individual Salary Report .3.119Salary Report by Location/Svc. Category .3.121Telephone Number Listings .3.124Individual Phone Number .3.126Phone (Home) Numbers by Location .3.128Home Phone Number(s) For Entire Service .3.132Chapter 4 Classification .4.1Classification, Edit Patient .4.1Classify Patients Individually .4.9Classify Patients by Ward .4.11Hemodialysis Patients, Classify/Count .4.14Recovery Room Patients, Classify/Count .4.16Unclassified Patients, Edit .4.18Patient Care Data, Print.4.21Classification Report .4.23Current Unclassified Patient Print, by Location .4.25Resource Management Reports .4.27Current Unclassified Patient Print .4.29Daily Patient Classification Summary By Ward .4.32Individual Patient Classification Reports.4.35Date/Time, Indiv. Classification Report By .4.37Ward & Date/Time, Indiv. Classification Report By .4.39Patient Category Totals-Midnight Acuity Reports .4.41vNursing V. 4.0 User ManualApril 1997
Table of ContentsChapter 5 AMIS .5.1Manhours Edit, AMIS 1106a .5.1Patient Category Totals-AMIS 1106 Reports .5.3Manhours Print.5.8FTEE Comparison (1106b) Report .5.13Chapter 6 FTEE/Workload Reports .6.1AMIS Workload Statistics Report .6.1Workload Statistics Report (Current) .6.7FTEE Reports.6.11Section 3 ClinicalChapter 1 Patient/Ward Information .1.1Location/Bed Section, Edit Nursing .1.1Location of Individual Patient, Print .1.3Ward Census, Print .1.5Chapter 2 Patient Assignments .2.1Patient Assignment Worksheet .2.1Brief Assignment Worksheet .2.2Complete Assignment Worksheet.2.4Chapter 3 Patient Plan of Care .3.1Patient Plan of Care, Edit .3.4Evaluation/Target Date & Order Status Edit .3.24Patient Plan of Care, Print .3.28Patient Problems to be Evaluated .3.34Chapter 4 Vitals/Measurements .4.1Vitals/Measurements Data Entry Menu .4.1Vitals/Measurement Data Entry .4.3Edit a Vital/Measurement Entered in Error .4.24Vitals/Measurements Results Reporting . 4.28Latest Vitals Display for a Patient .4.30Latest Vitals by Location .4.32Cumulative Vitals Report .4.34Print Vitals Entered in Error for a Patient .4.38V/M Graphic Reports .4.40SF 511 .4.42B/P Plotting Chart .4.42Weight Chart .4.42Pulse Oximetry/Respiration Graph . 4.42Pain Chart.4.42Chapter 5 Intake and Output .5.1Intake/Output Data Entry Menu.5.1Enter/Edit Patient Intake .5.3Enter/Edit Patient Output .5.10April 1997Nursing V. 4.0 User Manualvi
Table of ContentsStart/Add/DC IV and Maintenance . 5.13Start IV using a single lumen catheter .5.14Start IV using a multi-lumen catheter .5.17Hanging a unit of blood or blood products .5.20Discontinuing/converting an IV solution using Solution:Replace/DC/Convert/Finish Solution .5.23Finishing a solution and discontinuing the IV using Solution: Replace/DC/Convert/Finish Solution .5.25Replace Same Solution .5.26DC IV/Lock/Port and Site .5.28Documenting IV site care, tubing change and flushing of lines .5.30Add Additional Solutions .5.31Restart DC'd IV .5.33Adjust infusion rate .5.35Flushing the IV line, lock or port .5.36Intake/Output Results Reporting.5.37Print I/O Summary by Patient (by Shift & Day(s)) .5.39Print I/O Summary (Midnight to Present) .5.41Print I/O Summary (48 Hrs) .5.4424 Hours Itemized Shift Report .5.46Intravenous Infusion Flow Sheet .5.48Chapter 6 Miscellaneous Reports .6.1End of Shift Report .6.1Health Summary Report .6.3Section 4 Nursing Education ReportsChapter 1 Nursing Education Reports .1.1Nursing Education Reports, Print .1.1Training Report by Unit/Svc. Category .1.4Individual Training Report .1.103 Yr. Training Report by Unit/Svc. Category .1.13Individual 3 Yr. Training Report .1.18Mandatory Deficiency Report by Unit/Svc. Category .1.20Individual Employee Deficiency Report .1.26AA/Funding Requests Report (132 Col).1.29C.E. Training Attendance Summary Report (132 Col).1.32Section 5 Performance ImprovementChapter 1 QA Patient Classification .1.1Review/Edit Patient Classification .1.1Individual Patient, Review/Edit .1.3Ward, Review/Edit Classifications By . 1.5viiNursing V. 4.0 User ManualApril 1997
Table of ContentsChapter 2 Rank Listing of Patient Problems .2.1Rank Listing of Care Plan Data .2.1Chapter 3 QI Summary .3.1QI Summary Enter/Edit .3.1Edit All QI Summary Data.3.8Quality Performance Reports .3.13QI Summary, Print .3.14Glossary .GL.1Index .IN.1viiiNursing V. 4.0 User ManualApr
Nursing is a component of the Department of Veterans Affairs V IST A (Veterans Health Information Systems and Technology Architecture) program. It comprises software which is used to: 1) Plan and document nursing care provided to the veteran patient. 2) Support nursing administration by providing dat
