SC Site Entry (Progress Note-Palliative)
Flow Sheet – SC Pump Entry
This is a quick guide to SC Documentation in PARIS.
SC Site Entry (Progress Note-Palliative)
Basic principles:
- If client has SC Lines inserted but no pump attached, document only in the SC Section of the Progress Note-Palliative.
- The SC Site section and text in the Progress Note is used to document the SC sites and maintenance and hypodermoclysis.
- SC Pump information is entered in the ‘Flow Sheet-SC Pump’ Assessment; medications administered/dispensed are entered in the MAD-R
1. Number of sites = Number of SC sites inserted. Enter the # of sites, any details are entered in the text of the progress note.
2. Complications – indicate whether the sites are free of complications (Yes or No). Details are entered in the text of the progress note.
3. When the progress note is, you will see a list of the last 3 entries listing the # of sites and whether they had complications or not for your reference. If you look at the previous day’s note, you will see that day’s site count, information and the 3 visits prior (see above).
4. Tick Pump only if they are on a SC pump; if they are, SC pump information is recorded in the the ‘Flow Sheet – SC Pump’ Assessment.
5. Tick Hypodermoclysis only if they are receiving hypodermoclysis; put the infusion site in the Infusion Site box (see above); details are entered in the text of the progress note.
Flow Sheet – SC Pump Entry
Basic principles:
- If client has a SC Pump, document Pump information in the Flow Sheet-SC Pump Assessment
- Flow Sheet – SC Pump Assessment stays open as long as client on pump
- Always remember to COPY the most recent grid row to make sure the updated info gets populated over; you are responsible for reviewing and adding to your own grid entry
- The Infusion Sites, Pump Parameters, and the Due Dates will copy over (helpful for reference and planning); each part of the form can be modified as needed
- The Flow Sheet-SC Pump Assessment is used to document the SC pump care and maintenance
Medications administered/dispensed go in the MAD-R
1. Pump Settings and Infusion Maintenance (Up to 2 Pumps):
- Appear as yellow blank, unless you pick a value from the drop down list:
- Choosing a Delivery Mode from the drop down list will trigger the relevant parameter settings to appear.
- Choose NO PUMP when the client was on a pump, but the pump has now been discontinued; doing this removes that particular pump information without removing all the grid entry information
- Choose NO ENTRY when you have entered pump information in error (e.g., wrong client); doing this removes that particular pump information without removing all the grid entry information
2. Pump Settings (Particular Points):
- For both Continuous and PCA settings, you get the following at the top:
- [Screenshot]
- The ‘Infusion Site’ is mandatory, and copies over. It can be changed, though, whenever you need to change sites. The ‘Medication’ field is a free text ‘flag’ where you can put the specific medication that is going through the pump. IT DOES NOT REPLACE MAD-R DOCUMENTATION; it is there for safety reasons.
- The ‘Continuous’ setting values are self explanatory. The ‘PCA’ setting has a unique feature when you pick units:
- The type of unit automatically triggers the following: Concentration, Rate, Demand Dose, and Max Dose (for ease and consistency).
- Using the above example, you can see the concentration of 5 mg/ml, rate and max doses of 2 mg/hr, and demand dose of 2 mg. If you chose ‘mcg’, it would show mcg/ml, mcg/hr, mcg, etc.
3. Entered in Error: If you have completed the entire entry in error (e.g., wrong client), choose ‘ENTERED IN ERROR’.