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.
The nursing flowsheet is 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 support staff notes. Any numeric information entered in the flowsheet, such as vital signs, can be graphed for the day or for any extended period of time. In addition, four levels of warning ranges can be setup for each number field. If an entry is made into the flowsheet that is outside one of the warning ranges, the entry will be highlighted in a certain color.
In the nursing flowsheet, detailed data on oxygen therapy is tracked from simple to complex. Based on the type of support 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.
The nursing flowsheet is fully customizable to meet the specific needs of your site. Data fields can be added or removed from the flowsheet without the assistance of Isoprime or a local IT staff.
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.
The nursing flowsheet is used to track fluids from all sources and automatically calculate and classify fluid totals and calories. Output detail can also be tracked. Links to bar code scanners are available to scan from within the nursing flowsheet to allow scanning of the patient’s ID and breast milk containers for verification. Lot numbers of any feeding can also be scanned and tracked.
Based on the data collected in the nursing flowsheet, a nutrition calculator is provided that can display realtime data on a variety of nutrition (input and output) meaures. Each site can choose from over 80 calculations ranging from TPN and enteral feeding amounts and ratios, source of calories (lipids, protein, etc.), feeding history, growth statistics, and output measures.
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, Detailed data on oxygen therapy is tracked in the nursing flowsheet 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.
The respiratory therapist can use the nursing flowsheet to enter information they can use a special flowsheet designed to track only the data needed by the therapist. In either case, respiratory data entered by the nurse or respiratory therapist is stored and displayed together.
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.
NNM provides a means to track patient management information or patient assessment information that cannot be easily tracked using a typical data entry screen. This is done using the flexible General Tasks feature.
There are three types of General Tasks. Each of these is designed for a specific purpose:
This type of General Task is used to track a single task or activity completed by a single clinician. The task may not be directly related to clinical care, but is still important for patient management or general administration. For example, you can set up tasks for infant care instruction, CPR training, certain assessments, and even governmental reporting.
This type of General Task is used to track an activity that has multiple steps that may be performed over an extended period of time. For example, you can set up a checklist for parent education which could have all of the possible educational activities that can be provided over the course of the infant's stay in the NICU. As each step is performed, it can be checked as completed. A checklist General Task can also be used for nursing care plans.
Each step can be recorded independently by different clinicians. The clinician can include comments for each step, the date and time it was performed and the name of the clinician who completed the step (as it may be someone other than the clinician completing the checklist). If a step is not applicable, this too can be noted. The date/time the overall checklist was started and completed are also recorded.
Special checklist items can be setup to allow for multiple clinicians to record they performed along with the date and time they performed that item.
This type of general task is typically used as an assessment tool. It is presented in the form of a scoring tree and is completed by only one clinician.
A series of categories are established under which specific signs, symptoms and/or activities can be listed. Numerical ratings are assigned to each item. As individual items are checked, a total score for each category is tallied. Scores from each category are then combined into an overall rating.
The Finnegan Neonatal Abstinence Score tool provided in NNM is an example of a complex scoring tree.
A score tree General Task can be linked to certain cells in the nursing flowsheet. For example, a pain scoring General Task can be linked to the pain score cell in the nursing flowsheet so that the scoring tool can be used directly from the flowsheet and be available for reference after the overall score is entered.
Reminders for any type of General Task can be generated automatically based on reminder rules. General Task reminders can also be created manually. When a General Task is completed, the associated reminder will be marked as completed. The completion of a General Task can also be configured to trigger a reminder for any other action in NNM for which a reminder can be generated.