HOW TO:

ACCESS ALERTS IN ROUTINE DAILY CARE RECORDS (Healthcare Assistants)

Once you have logged in –

Click on Routine Daily Care.

Choose floor / unit/ ward or you can choose or All Wards.

The residents name and photograph will appear on the page so you know you are in the correct residents records.

By clicking on the ‘Get Alerts’ icon, you will be provided with essential key information about the resident.

How To:

ACCESS HCA CARE UPDATE FORM IN ROUTINE DAILY CARE RECORDS

Healthcare assistants (HCA)

Once you have logged in –

Click on Routine Daily Care.

Choose floor / unit/ ward or you can choose or All Wards.

The residents name and photograph will appear on the page so you know you are in the correct residents records.

To find information about the residents care needs or changes in care e.g. continence, mobility, etc can be accessed by clicking on HCA Care Update.

This form is completed by the nurse.

HCA Care Update: Information about the residents care needs or changes in care e.g. continence, mobility, nutrition etc. This form is completed by the nurse.

To look at old / archived forms choose one from the list below and click on the one you want to view.

To leave this page and return to previous page (RDC), click on close button.

How To:

ACCESS MOVING AND HANDLING CHART IN ROUTINE DAILY CARE RECORDS

(Healthcare Assistants)

Once you have logged in –

Click on Routine Daily Care.

Choose floor / unit/ ward or you can choose or All Wards.

Choose a resident.

The residents name and photograph will appear on the page so you know you are in the correct residents records.

The food diary box should be ticked indicating that the food diary needs to be completed for this resident.

You have now view the resident moving and handling chart.

To exit the moving and handling chart and return the residents routine Daily Care Records (RDC) just click ‘close’.

You have now returned to the residents Routine Daily Care Records (RDC).

How To:

Archive A STAFF MEMBER (USER DETAILS)

After login

Click on Administration.

Click on User Management.

Click on Archive.

Click on View Active Users.

Right Click on Active Users and select Archive.

When you have finished, the user will no longer be able to log-on. The records they edited or added in the past remain associated with this username.

You can add this user again but should only use this username for the same person.

HOW TO:

Change Group Permissions

When you want to allow a user access to something, or restrict their access, you use Group Permissions

Each user is a member of a group, and their level of access depends on what has been decided by the administrator for that user group.

The options are:

Allowed Access Users in the user group are allowed to read, add and edit records.

Not Allowed Access The button for the feature will be disabled and the users in the user group will not have access at all.

This can also be changed later. To do this see the Help Files: ADDING A STAFF MEMBER and EDIT A STAFF MEMBER.

After login.

Click on Administration.

CLICK ON Group Permissions.

Choose a User group to edit.

You will then be shown the current permissions for each section of Care Monitor.

Chose a level of access: Allowed Access

Or Not Allowed Access.

When finished Click Close.

When finished editing group permissions, you will need to re-start Care Monitor for the permissions to take effect.

As an example

If you have a Care Assistant, the default settings are that they have access to Routine Daily Care, Activities, Staff Menu, Supervision Recording, Daily Event Log, About Me, Summary Record, Resident Diary, Documents, Terminal Care Plan, Upload Photos and Global Diary.

If you want the Care Assistant User Group to be allowed to view Assessments and Care Plans:

Make sure they have: Allowed Access to the Resident Care Menu and Read Only Access to Nursing Assessments.

With this access, they can look at all Assessments and Care Plans, including the Nursing Assessment Tools such as MMSE and Wound Assessments. They will not, however, be able to edit them.

How To:

COMPLETE A COMPLAINTS FORM.

Once you have logged in –

Click on Risk Management.

Click on ‘Complaints reporting and analyses.

You can click on ‘Complaints Process Map’ to see the steps of the complaints process.

A PDF will appear with the steps of the Complaints process. Just click on the X to leave the process map.

You can download and print off a paper version of the complaints form for completion by clicking on ‘Download Blank Paper Form’.

Click on the little printer icon or ‘File’ → ‘Print’ on the top left of the screen to print off the form.

To leave the PDF form click on the X in the top right hand corner of the screen.

Click on ‘New Complaint’ to record a new complaint.

Scroll down to reveal the rest of the complaints form.

Don’t forget to check the date and time of the receipt of the complaint as todays date and the current time will automatically appear.

Record the type of complaint e.g., verbal, written, etc. and the category of the complaint.

Record the complainant’s details.

Record the details of person who received the complaint.

Document the details of the complaint.

Where the complaint was resolved at the point of contact –tick yes box and record what was done to resolve the complaint.

Where the complaint was not resolved at the point of contact, record what is to happen next.

The PIC/Complaints Officer will complete the following sections of the form e.g., likelihood of recurrence, consequences, information regarding investigation carried out and action plan.

The PIC/Complaints Officer should also record the outcome f the complaint e.g. complaint is satisfied with outcome and complaint is closed or the complaint has been referred to an independent appeals person.

Click on Close to exit the complaint. The complaint will save automatically.

If the complaint is still open, you can view and edit/update this complaint in the future by clicking on ‘View Existing Open’.

If the complaint is closed, you can view (not edit/update) this complaint in the future by clicking on ‘View Closed Complaint’.

Click on Close to exit back to the Home page.

How To:

COMPLETE A FALLS ANALYSIS.

Once you have logged in –

Click on Risk Management.

Click on Falls Reporting and Analysis.

When you have chosen the resident, their photo will appear.

To view residents history of falls click on Falls Analysis by Resident.

Choose a time period by entering a date from and to when you would like to view the falls.

Then click on view.

You can print out the entire report.

A list of all the recorded falls within the chosen time period will appear in chronological order starting with the most recent.

You can print out the entire report.

Click on Close to exit the residents analysis and return to the previous page.

When you have chosen the resident, their photo will appear.

To view all residents falls click on Overall Falls Analysis.

Choose a time period by entering a date from and to when you would like to view the falls.

Then click on view.

How To:

COMPLETE A FALLS INCIDENT AND ASSESSMENT FORM.

Once you have logged in –

Click on Risk Management.

Click on Falls Reporting and Analysis.

When you have chosen the resident, their photo will appear.

Click on New Falls Report to complete an incident form on a new fall.

Check the date as todays date will automatically appear in the box.

Complete all the boxes on the form.

Scroll down to reveal the rest of the form.

Remember: A controlled fall (where a resident is assisted to a lower level e.g., floor or chair, by a member of staff) still needs to be recorded as a fall.

You can document that it was a controlled fall in the Description of Events box.

Click on Print to print the form.

Click on Close to exit and return to the previous page.

How To:

COMPLETE A FOOD DIARY IN ROUTINE DAILY CARE RECORDS (Healthcare Assistants)

Once you have logged in –

One Click on Routine Daily Care.

Choose floor / unit/ ward or you can choose or All Wards.

The residents name and photograph will appear on the page so you know you are in the correct residents records.

The food diary box should be ticked indicating that the food diary needs to be completed for this resident.

Click into the Nutrition Domain.

In the Nutrition Domain, click on the food diary icon to open.

When the chart appears don’t forget to check the date and time –you can change them if you need to.

Enter necessary information into the appropriate boxes.

Recent entries will appear in the large box above so they can be easily viewed.

You can also view many entries over a specified length of time e.g. three days by choosing the days you would like to look at.

Once you have chosen a time period, click view to see the diary.

To close the Food Diary and return to the Nutrition Domain, just click on Close.

When you close the food diary, you are now back in the Nutrition Domain.

How To:

COMPLETE A RESIDENT ASSESSMENT.

Click on Resident Care –Current Resident.

Click on choose a resident (small arrow down on right hand side).

Choose a resident by name.

Once you have chosen your resident, their name and photo will appear on the screen.

Once you have chosen your resident, click on Assessment and Care Plan.

Choose the Domain you want to write the care plan in e.g., Cognition.

When a domain is chosen the Domain Screening Assessment will appear.

To add or edit information click on Update Assessment.

Having clicked update assessment, boxes in the assessment can be ticked.

Where text is required to be entered a text box will appear.

Check to ensure the date of assessment is correct as todays date will automatically appear.

Once the screening assessment is completed, the completion box should be ticked.

Once the screening assessment is completed, click on save when you have completed the screening assessment. If you forget to save the information, it will automatically save for you.

You can also access old / previously completed / archived screening assessments by clicking on View Archive Button.

Click on an archive record to view it.

The old / previously completed / archived screening assessment will appear. You can view it  but you can’t edit it.

To leave the old / archived screening assessment click on close. This will bring you back to the previous page / current screening assessment.

Some Screening Assessments will provide a prompt when you tick a particular box.

These prompts are instructing you to complete a risk assessment or task.

Risk Assessments are found in the Assessment Tools button.

Generic Risk Assessment in risk assessment tools.

Don’t forget to click update risk assessment to allow entering text or editing.

Using a generic Risk Assessment

•A generic risk assessment is only used where another tool e.g. Waterlow, MUST, Stratify, etc.  is not available (these tools are found in ‘Other Tools’).

•Examples of when a generic risk assessment may be required are as follows:

Choking

Absconsion

Violence & Aggression

Self harm

(this list is not exhaustive).

Enter the risk/hazard e.g., the behaviour the resident displays.

Enter who could be harmed e.g., resident, staff, visitors, other residents, etc.

Enter how they could be harmed e.g.  Knocked down by a car, physically assaulted, etc.

Consequences

Negligible: Minimal injury requiring

no/minimal intervention or treatment.

Minor: Minor injury or illness requiring minor Intervention.

Moderate: Moderate injury requiring

professional intervention.

Major: Major injury leading to

long-term incapacity/ Disability.

Catastrophic: Incident leading to death. Multiple permanent injuries or irreversible health effects.

Likelihood

Rare: This will probably never happen/recur.

Unlikely: Do not expect it to happen/recur but it is possible it may do so.

Possible: Might happen or recur occasionally.

Likely: Will probably happen/recur, but it is not a persisting issue/

circumstances.

Almost Certain: Will undoubtedly

happen/recur, possibly frequently.

When you enter the Likelihood and Consequence into each text box a risk score will automatically be calculated.

The coloured boxes indicate the risk rating, that is:

Extreme, High, Moderate or low.

Don’t forget to check that the date of the assessment and date of review are correct.

In the text box, type in the control measures put into place to reduce the likelihood of the risk occurring.

To save the risk assessment, click on save. If you forget, it will be automatically saved for you.

Alternatively. Click on another button to redirect to another section e.g. screening assessment or care plan.

To exit the risk assessment and return to the previous page click close.

To access previously completed/ archived assessments, click on risk archive.

Choose the archived risk assessment you want to view and click on it.

You can view the previously completed/ archived assessment but you cannot edit it.

To return to the previous page / current risk assessment click on close.

To access additional assessment tool e.g., Water low, click on ‘Other Tools’.

Other Tools containing assessments for each domain e.g. falls risk assessment, MUST,  Geriatric Depression Scale, MMSE,  Abbey Pain Scale, etc.

Clicking on your chosen assessment tool will open it.

To complete the assessment, click on new to be able to activate it.

Don’t forget to check the date of assessment as todays date will automatically appear.

To save the completed assessment, just click close.

To access previous /archived assessments, just click on the chosen assessment.

You can view the previously completed/ archived assessment but you cannot edit it.

To exit back to the current assessment, click on close.

To exit the screening assessment, assessment tools or the entire domain, just click on close.

How To:

COMPLETE A RESIDENTS NURSING NARRATIVE NOTES.

Click on Resident Care –Current Resident.

Click on choose a resident (small arrow down on right hand side).

Choose a resident by name.

Once you have chosen your resident, their name and photo will appear on the screen.

Once you have chosen your resident, Click on Nursing Narrative Notes.

The residents name and photo will appear to ensure you are in the correct notes.

Click on ‘Help’ to reveal a PDF document that provides guidance to nurses on writing narrative notes.

PDF document that provides guidance to nurses on writing narrative notes.

Previous Narrative Note entries will appear in Current Notes.

Type new narrative note entries in New Narrative Notes.

Remember to check the hca’s Routine Daily Care records before you write your narrative notes so as to know what care the resident received during the shift –just click on View RDC Record.

The Routine Daily Care Records (RDC) will provide information on what care the resident received during the shift and may assist you with what to include in your narrative notes.

You can also look at previous days  Routine Daily Care Records (RDC) by choosing the dates you want to view.

You can also just look at one particular domain’s records e.g., breathing or nutrition by using the ‘filter’ button.

To return to narrative notes –just click Close.

You can also check the residents most recent vital signs prior to writing you narrative notes, if needed by clicking on ‘View latest Vitals’.

To return to narrative notes –just click Close.

You can view older nursing narrative notes by clicking on ‘Historical Notes’.

Choose the dates (time period) you want to view and click on ‘View’.

To return to current narrative notes –just click ‘Close’.

When an incident or event happens, you are required to record it in the Daily Event Log (as well as writing about it in the nursing narrative notes). This is to allow for collecting of data / figures on the number of events such as the number of falls or skin tears or infections in the centre.

The ‘Daily Events Log’ can be found on the right hand side of the screen.

Daily Event Recording

You will need to record resident events in the Daily Event Log e.g. a fall, skin tear, urinary tract infection, etc, on the day that the event occurs. Please do not record the same event/incident twice e.g. where a resident presents with an infection such as a urinary tract infection, it should only be recorded once on the first day of the infection and not on any additional days that the infection continues.

Just click on the appropriate event button once. You can click on more than one event, if you want e.g. Fall and Skin Tear.

To return to current narrative notes –just click ‘Close’.

You should also review the ‘Status of Resident’ each time you write your narrative note by clicking on ‘Update’ and editing the tick boxes as required.

To exit the residents Nursing Narrative Notes –just click ‘Close’.

Things to Remember when completing the Nursing Narrative Notes.

Before starting your narrative notes, don’t forget to review the status of resident.

Don’t forget to check the Hca’s daily care records (RDC) before you write your narrative notes! Also, don’t forget any Daily Event recordings!