Perinatal Data and Demographics
Demographic and medical history data for both the mother and infant is tracked. The maternal data includes perinatal history such as medications, complications, risk factors, screens, prenatal care, and delivery details, along with extensive demographic data. Infant data includes demographic data along with detailed information about the birth.
Labs such as CBC, blood gas, bili, blood screen, LFT, electrolytes, medication levels, urine test, toxicology screen, and a variety of cultures can be tracked with multiple entries per day. Infrequent or very unique lab test can also be tracked through the special labs feature. A combined view of lab data is provided that can display all lab results for a particular time period and generate a graphical display of individual readings over that time period.
Diagnostic exams such as head ultrasound, CT scan, hearing test, and eye exam can be tracked with detailed findings and a notation for when the next exam should be done.
System-based physical exams can be tracked using common findings available through drop-down selections. Free-form text is available along with user-defined selections for findings and typical exam defaults. Prior exams can be copied and modified for current findings. Detailed vital signs are also tracked.
A summary of the day’s fluid/nutrition can be entered that tracks fluids from all sources and automatically calculates and classifies fluid totals and calories. Output detail can also be tracked.
The optional Nursing Module can be used to track the hour-by-hour activities of nursing care. Typical flowsheet data such as IVs, vitals, monitors, intake, output, assessments, nursing care, wound/line care, environment, parent interactions, cardio-respiratory events, and O2 therapy can be tracked. Typical calculations for fluid totals, calories, GIR, and output are done automatically. The nursing data is entered and viewed in the form most commonly used by the nursing staff – the flowsheet. All selections are user-defined and each flowsheet entry is associated with the person who made it. Revisions are tracked and text comments can be entered for any type of data. Nursing flowsheet data can then be automatically retrieved into nursing and physician notes.
Detailed data on oxygen therapy is tracked from simple to complex. Based on the type of therapy being provided, data is collected on delivery mode, vent settings, and patient status. Delivery modes range from mask, to nasal cannula, to CPAP, to volume or pressure ventilation, to high frequency ventilation. Additional data can be tracked by the respiratory therapist and the combined nursing and respiratory therapy data is stored and displayed in one place.
Patient diagnoses are tracked noting the onset and resolution times and the staff member making the diagnosis.
Patient procedures are tracked noting the staff member performing the procedure, the time of the procedure and the reason for the procedure. Procedure comments can be collected and later used to generate text for an admission note or procedure note.
Ordered medications are tracked and cross-referenced to administered mediations. Medications administration can be done through IV entries and a medication flowsheet.
Computer-based images can be managed and accessed. Patient images with comments can be viewed along with images of people who may interact with the patient.