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VESALIUS
Nursing Support System
User Manual
Document Label: GEO-NSS-UM
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Document Authorisation
Project Name: VESALIUS – Nursing Support System Module
Prepared By
Name: NOVA 23-Aug-2016
Signature:
Reviewed By
Name: Tham Thi Van Anh 23-Aug-016
Signature:
Authorised By
Name:
Signature:
Acceptance By
Name:
Signature: Date:
Name:
Signature: Date:
Distribution List
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This Functional Specification is subject to document control. For identification of amendments, each
page contains a release number and a page number, which includes the section number.
Changes will only be issued as complete replacement sections covered by a signed release notice.
TABLE OF CONTENT
1 FUNCTIONS ................................................................................................... 10
1.1 REGISTER PATIENT ............................................................................................................... 10
1.1.1 Visit Info ......................................................................................................................... 10
1.1.1.1 Patient with double registration ................................................................................. 11
1.1.1.2 Patient with Active Last Visit 3rd Party Payer ........................................................... 11
1.1.1.3 Patient with VIP level ................................................................................................ 12
1.1.1.4 Patient with outstanding bill amount ......................................................................... 13
1.1.1.5 Blacklisted Patient ..................................................................................................... 13
1.1.1.6 Patient with Notes Alert ............................................................................................ 14
1.1.1.7 Patient Registration ................................................................................................... 14
1.1.2 3rd Party Payer................................................................................................................ 17
1.1.2.1 3rd party without LG ................................................................................................. 17
1.1.2.2 3rd party with LG ...................................................................................................... 19
1.1.3 Biodata............................................................................................................................ 23
1.1.4 Guarantor ....................................................................................................................... 25
1.1.5 Next of Kin ...................................................................................................................... 27
1.2 MANAGE REGISTRATION ...................................................................................................... 29
1.2.1 Registered Patients ......................................................................................................... 30
1.3 MANAGE QUEUE ................................................................................................................... 32
1.4 CLINICAL DOCUMENTS ......................................................................................................... 34
1.4.1 Clinical Documents ........................................................................................................ 34
1.4.1.1 Clinical Documents → Medical Certificate/ Time Chit ............................................ 35
1.4.1.2 Clinical Documents → Referral Letter ...................................................................... 37
1.4.1.3 Clinical Documents → Patient Advice...................................................................... 38
1.4.1.3 Clinical Documents → Prescription .......................................................................... 40
1.4.1.4 Clinical Documents → Lab Report ........................................................................... 42
1.4.1.5 Clinical Documents → Radiology Report ................................................................. 44
1.4.1.6 Clinical Documents → Future Orders ....................................................................... 45
1.4.1.7 Clinical Documents → DI Report ............................................................................. 46
1.4.1.8 Clinical Documents → OT Report ............................................................................ 48
1.4.1.9 Clinical Documents → Handover Notes ................................................................... 49
1.4.1.10 Clinical Documents → Vaccination .......................................................................... 51
1.4.2 Prescription .................................................................................................................... 52
1.5 OP NURSING ......................................................................................................................... 57
1.5.1 OP Nursing → Queue List .............................................................................................. 58
1.5.1.1 OP Nursing → Facesheet .......................................................................................... 61
1.5.1.2 OP Nursing → Visit view.......................................................................................... 63
1.5.1.3 OP Nursing → Clinical Template ............................................................................. 63
1.5.1.3.1 Clinical Template – create new clinical template .....................................................64
1.5.1.3.2 Clinical Template – annotation in added template ....................................................65
1.5.1.3.3 Clinical Template – view clinical template history ...................................................66
1.5.1.3.4 Clinical Template – unlock a template ......................................................................68
1.5.1.3.5 Clinical Template – update/delete a clinical template...............................................69
1.5.1.4 OP Nursing → Nursing Notes ................................................................................... 70
1.5.1.4.1 Nursing note – create new case note .........................................................................70
1 FUNCTIONS
2. Enter the patient’s PRN or any other criteria to search for patient. System will return
search result if any.
Note: If there is only one search result, system will redirect to the registration page detail
5. Click on and system will redirect to the Register Patient search page.
7. If the patient does not have right to access the patient record due to patient’s level is
higher than the user’s: user is not allowed to proceed further. System will prompt:
Close the message and system will redirect to the Register Patient - main page.
8. If user has right to access patient's record; system will prompt the patient's level.
Click on button to acknowledge and close the message and system will redirect to
Visit Info page to proceed with patient registration.
10. Click on button and system will redirect to the Visit Info page to proceed with patient
registration.
14. Click on and system will redirect to the Visit Info page to proceed with patient
registration.
16. Enter or edit any of the following fields (* as mandatory fields) if applicable:
Source of Referral*
Payment Class*
Case Type*
Charge Category*
Specialty
Attending Dr*
Third Party
Referring Dr
Note:
Check the Third Party checkbox if the patient has insurance coverage. Upon clicking on
button, system will direct the to third party screen. Otherwise, registration is
completed.
17. If the patient has on-arrival (OA) orders, system will display button.
User can:
Convert on-arrival order to current order
Complete registration.
22. To ignore the future order (not convert future order to current order): click on button
to close the future order window..
23. If the Third Party checkbox is checked, system will redirect to 3rd Party Payer page after
registering the patient.
24. In the upper half section of screen: add new 3rd party
a. Select 3rd party payer from dropdown list
rd
Note: in the 3 Party Payer field, type in the first few characters of the name of the
rd
3 party payer, then press the <Tab> key on the keyboard or click on the to
retrieve the first 100 records, and select the correct payer.
b. Select plan
c. Update member ID
d. Select effective from date
e. Select effective to date if applicable
f. Click on button.
g. New 3rd party payer with a plan will appear in "Patient's Existing Third Party"
section at the bottom-left of the screen.
26. To update Coverage Limit value: in selected third party list on the right
a. Click on .
b. System will display "Edit Coverage Limit" window.
27. In the upper half section of screen: add new 3rd party
a. Select 3rd party payer from dropdown list
rd
Note: In the 3 Party Payer field, type in the first few characters of the name of the
rd
3 party payer, then press the <Tab> key on the keyboard or click on the to
retrieve the first 100 records, and select the correct payer.
b. Select plan
c. Update member ID
d. Select effective from date
e. Select effective to date if applicable
f. Enter LG details, including:
LG Reference number
LG total coverage: leave the field empty to indicate unlimited coverage
CAP amount OP Visit
CAP amount IP Visit
OP coPayment and IP coPayment
Note: OP CoPayment and IP CoPayment: value entered in this field is the
minimum amount required to be paid by the patient for each bill on the
respective visit. The bill cannot be finalized if the patient payable is less
than the value indicated in this field. Advise to left the field blank if there is
no information from LG.
OP visit count
IP visit count
Remarks
g. Click on button.
h. New 3rd party payer with a plan will appear in "Patient's Existing Third Party"
section at the bottom-left of the screen.
b. Click on button.
c. Selected 3rd party payer will appear in "Current Visit Selected Third Party"
section on the right.
1.1.3 Biodata
33. Select Biodata tab to update the patient’s bio-data.
34. User is required to enter mandatory fields (* as mandatory field) in Basic Information and
Other Details.
35. User can enter and save multiple entries of Address, Contact and Document Type by
clicking on button.
1.1.4 Guarantor
40. Select Guarantor tab to create/update the patient’s guarantor’s information.
41. If the Guarantor information is existing in the system: select guarantor from the
dropdown list.
Note: for quick search, user can key in the PRN/ Person’s name, then press the <Tab> key
on the keyboard. The user can also click the to retrieve the first 100 records and select
the correct person.
42. If the Guarantor record is not found in the system: click on button to create new bio-
data for guarantor.
44. Click on button. The user will be directed back to the Guarantor tab.
45. Enter or edit any of the following fields (* as mandatory fields) if applicable:
Effective From *
Effective To
Priority
49. Perform similar steps in Guarantor section to create new next of kin.
50. For next of kin, user is required to provide relation of next of kin to patient by select an
option from relation dropdown list.
Note: to remove existing next of kin, click on the related person record, and click on
button.
1. From Vesalius Home page, click on Nursing module icon and select Manage Regn
function. System will display "Manage Registration" main page.
2. Enter any of search criteria. Search result will appear if there is.
3. Select a patient from search result and system will redirect to Manage Registration detail
page.
Note:
Only authorized user can change charge category.
If the user is not authorized to modify the charge category, a pop-up message will
be displayed.
1. From Vesalius Home page, click on Nursing module icon and select Manage Queue
function. System will display Manage Queue - main page. The page will display list of
patients who are waiting in all doctor’s queue.
Note:
System will only retrieve the patients who is in primary queue of a doctor. If doctor
starts consultation session, the patient will not be displayed in Manage Queue list.
System will retrieve patient from current clinic if user logged in to a clinic location.
Note:
Icon denotes primary doctor. Primary doctor cannot be removed.
Icon indicates patient is waiting in consultation queue.
Icon indicates patient consultation is in-progress.
Icon indicates patient consultation is completed.
6. To change the sequence of doctor that patient is going to visit: click on (move up)
button or (move down) button to re-arrange the sequence.
3. If there is only one patient record found, system will redirect to patient’s Clinical
Document page. Otherwise, select patient from the search result.
5. Click on button to print. Else, click on the button to abort the process.
Note: User can setup option to view before print / print direct and default printer for direct
printing of medical certificate in System Admin -> Printer -> Label Printer -> Clinical Label
Type: MEDICAL CERTIFICATE
5. Click on button to print. Else, click on the button to abort the process.
Note: User can setup option to view before print / print direct and default printer for direct
printing of patient advice printing in System Admin -> Printer -> Label Printer -> Clinical
Label Type: PATIENT ADVICE
4. Select any record by clicking on it. System will display laboratory report in a window.
5. Click the icon to analyze the lab results of that particular lab item if applicable.
4. Select any record by clicking on it. System will display radiology report in a window.
Note: the reports are grouped by each visit, followed by order date. Latest report is
displayed on top.
4. Select any record by clicking on it. System will display DI report in a window.
Order Date
Report No
Description
3. Select any record from search result or from default listing. System will display OT report
in a window.
1. Select Document Type: Handover Notes. System will display available handover notes
for each visit in chronological order. Handover notes in latest visit will be on top.
2. Click on button
4. Mouse over to the icons to view episode' status in the left menu:
a. Episode with icon - CLOSED.
b. Episode with icon - ACTIVE
1.4.2 Prescription
This function allows a nurse
Mark drugs from doctor's prescription as external - drug to be bought outside from
hospital. This can be done one time for each prescription in a visit.
Print out the prescription for Rx that is marked as external for patient to fill-up elsewhere.
Once marked, the drug will not be charged nor will it appear in pharmacy module for dispensing.
2. Select the visit number from dropdown list. System will display list of prescription in
selected visit.
3. Select a prescription record. System will display list of medications which were ordered
by doctor.
Note:
User can only mark Rx with status PRE, I (prescribed, in-progress) to become
external.
Rx with status PRE, F (prescribed, finalized) and dispensed (DIS,I and DIS,F) will
not appear in the list.
If there is external Rx ordered (Consultation function: Rx > External Rx tab), it will
be displayed in List of External Order section at the bottom.
Note: at this step, user still can reverse the change by uncheck the checkbox and click on
button again.
8. Upon confirmation:
a. System will print the prescription for selected Rx
b. Close the printing, Rx which is marked as external will have checked flag.
c. No other drug can be marked as external, regardless of drug' status. System will
disable the selection and save/finalize button.
1.5 OP Nursing
In this module, nurses can use the OP Nursing function for the following:
Sample taking for laboratory test
View EMR
Perform procedure
Write nurse's notes
Record vital signs, alerts and allergies
1. From Vesalius Home page, click on Nursing module icon and select OP Nursing
function. System will redirect to Nursing - main page: Queue List tab, showing the
queue list in the current log-in location by default.
Note: Refer to Queue List section for more explanation about the queue list.
2. Before performing services to a patient, the nurse/doctor needs to login first. If the user
is an authenticated nurse, system will auto-login this part for nurses only.
5. The authenticated login users will appear in the Authenticated User(s) section.
6. If the user has been idle for more than 3 minutes since the last 'end session' or 'exit',
the system will force the user to login again whenever user tries to pick up a patient.
7. Enter the password of one of the previous users or enter with a new user ID and
password, then click the button. Else click the button if the user does not wish to
login.
Note:
Show Primary Queue: If there is at least one open Lab/ Procedure Service and no
partially performed orders, or at least one open order which has been setup to be
performed at the workstation’s location.
All Locations: See all visits with open orders regardless of perform location.
Show Patients Seen: To see the list of patients with closed sessions.
Secondary Queue: Lists only visits with at least one order which is partially
performed for the day’s registered patients.
The first column indicates the registration types.
Gender of patient
Female patient
Male patient
Purposes
Urgent Orders (lab/ radiology) waiting to be performed
Investigation orders waiting to be performed
Procedures waiting to be performed
Completed lab/radiology reports for doctor’s review
As default, the nurse will enter non-ordering (non-OE) mode. This will not lock the
patient’s account and allows nurse enter clinical information.
In order to perform ordered services from doctor, or to order services to patient, enable
ordering mode is required.
6. Upon confirmation, system will redirect to Order feature in order to perform orders from
doctor. Refer to OP Nursing → Orders for detail.
b. System will redirect to Assess > Diagnosis page. Refer to Assess – Diagnosis
section for detail.
1. Go to Visit View by clicking on icon. System will display latest visit information
(current visit) as default.
[HERE] Refer to View EMR by Visit for detail how to view the EMR using visit view
A C
2. Enter the necessary information by answering questions in selected template and click
on button
3. Upon save, system will display a record in Past Clinical Template panel - as in-
progress status
4. Icon to indicate the template is locked / unlocked: - locked. Only user who created
can unlock it. If the current physician is not the one who added, system will prompt:
2. Annotation screen will appear. There will be a predefine image attached on the clinical
template
3. Use drawing tools to annotate the image and provide remarks for each drawing if
needed
4. Click on button to save the changes. After save, annotation will appear in repository
1. Upon save a selected clinical template: - History button will appear at the bottom of
the template
2. Click on button, system will load the history of current clinical template
3. Click on icon appear next to each history header to view the details of template
added on respective date/time
2. When the template is finalize, system will display instead – finalized and locked
3. To unlock:
a. Click on button. System will prompt:
3. To delete a finalized template: unlock the template and perform similar steps
a. Click on button
b. Enter chief complain
c. Enter nursing note content in the editor and use the tools inside editor to format
the nursing note content.
d. Click on button.
Click to use
canned text
The Canned Text needs to be setup in Clinical Mgmt Maintenance Canned Text, for
Function EMR.
a. Click on button
b. Select a canned text from canned text list
c. System will populate
Chief complaint – canned text title
Editor – content from canned text
d. Update chief complain
e. Update nursing note content in the editor and use the tools inside editor to format
the nursing note content.
f. Click on button.
c. Click to select the case note content which is going to be copied over.
f. Upon confirmation, system will create a nursing note with exact content/chief
complaint in current visit (in-progress)
g. Update the chief complaint and content
h. Click on button.
4. Upon save, nursing note will be displayed in Case Note History section.
5. During entering case note conent, if user browse different tab or click to close IE without
save the case note content, prompt message will appear:
Select "Leave this page" option: the content of case note will not be save.
Select "Say on this page" option: to stay at the case note tab and continue
working on case note content.
1. In Case Note History section: click on Summary or Detail option to view case note by
summary or detail.
2. Select a record in Case Note History, system will populate the case note detail to the
editor area.
3. For in-progress case note, nurse can update the content and click on button to save
Note – user can only update his/her own case note.
b. Click on button
c. System will prompt:
Note - for finalized case note, the content will be populated without formatting
feature in the editor
b. Click on button
c. System will prompt:
Perform the vaccination by selecting the area where the type of vaccination (Y-axis) and
the period (X-axis) meet
When there is physical item that tied to the vaccination from the vaccination setting:
3. Physician can:
a. Capture external vaccination administration – vaccination was done outside
hospital. Refer to Vaccination –external vaccination administration
OR
b. Capture vaccination administration – done in hospital. Refer to Vaccination –
vaccination administration
2. Check “External” checkbox. System will enable Perform Date and Perform Time fields.
Site*
Outcome
o Positive - vaccination administration is successful.
o Negative - vaccination administration is not successful.
o None of the option is selected – unconfirmed outcome
Perform Date & Perform Time – select actual perform date/time. Past date/time is
allowed.
Remark (if any)
- Successful entry
OR
- Unsuccessful entry
OR
c. Update Outcome
d. Click on button. System will prompt:
c. Click on button. System will display blank information for new data entry
10. When there is multiple entries, they can be viewed using and button:
Current entry:
Previous entry
- Successful entry
OR
- Unsuccessful entry
OR
c. Update Outcome
d. Click on button. System will prompt:
c. Click on button. System will display blank information for new data entry
8. When there is multiple entries, they can be viewed using and button:
Current entry:
Previous entry
2. Update Date/Time
2. Click on button at the bottom right corner of the page. System will prompt:
4. Upon confirmation, the record will be removed and disappear from the list.
In each record:
Icon to represent allergy/alert type
Alert/Allergy description
- (from left to right) view all, problems, drug allergies, general alerts,
medical alerts.
1. In Problem panel:
2. To add problem:
a. Click on . System will display Problem screen
b. Physician can choose problem from Standard List (on the left) or User Defined
List (on the right) – ONE in each list
Note – user can use Search field to search in User Defined List
c. Click on to save.
d. Upon save, system will display the problem in Timeline
b. Select reason
c. Enter username & password
d. Click on button
e. System will display inactive record in timeline – in grey.
1. Click on in any panel: General alert or General Allergies. System will display
General Alert/Allergy screen
Note – system will default the cursor to the text field in respective panel where
button is clicked
For e.g: Click on button in General Allergies panel, cursor will be defaulted to
the text box inside Allergy Type List on the right.
2. Click to select any alert/allergy tile: one selection can be made in each panel
3. Enter value to the text field below each section for more input
1. Nurse can search for diagnosis. Search can be done within preference set or search
within all available ICD list
a. Select a preference list (to search within pref. list) OR select the first option
“Quick Select” to search in all available ICD
b. Select diagnosis group
c. Select ICD type list
d. Enter search criteria
Note – system will return maximum first 100 records found. User should refine the search
criteria to search for correct diagnosis.
3. Click to select the diagnosis. System will display diagnosis detail panel
5. Click on button. Added diagnosis will appear in timeline – with icon. Mouse over to
the icon to see ICD code.
a. When the patient does not have any diagnosis entered, newly added diagnosis
will be considered as primary diagnosis. The record will be displayed in bold
b. When the patient’s already had active diagnosis, physician has to update primary
diagnosis if needed. Refer to Diagnosis – timeline section for detail steps.
a. Enter free text diagnosis and remark to 2 fields at the bottom of screen
b. Click on button.
c. Free text diagnosis will be added to timeline – no icon in front.
1. Timeline view:
Primary diagnosis:
Closed diagnosis:
The screen includes search section on the left and timeline on the right.
c. Use dropdown list in each service type to filter the search result by item group.
For lab/rad service type: the filter is for lab class and radiology class.
Physician can order a service in current visit using 2 methods: quick order and order using order
detail.
Order using order detail is used when there is change subjected to the order, for e.g: different
priority, change in perform location or to give order remark, etc… It can also be used to order for
future.
AH service BTS
c. Click on button to order. Else, clic on button to close the order detail
window.
d. Upon order, it will appear in Timeline. Refer to CPOE – Timeline for detai.
b. System will display future order (if there is) – with indication below Timeline
a. An order is tied to a visit. System will display visit number (Account No.),
registration date and visit type (icon)
b. List of icons and actions that physician is allowed to perform will be display. Icon
in grey – action is not applicable. Refer to following steps for detail.
A DI, procedure, allied health and blood transfusion service can only be deleted if the
service has not been performed.
A past visit’s ordered service (even at “in-progress” status) cannot be deleted.
4. Click on button to place the order. Else click on button to abort the action.
3. Select LMP date (optional) – applicable for female patient, between 12-15 years old.
2. Select a template on the left menu and fill up the template content
4. After save, the associated template will have in-progress status. Update and delete are
allowed.
5. Enter content to consent using the text editor or use canned text.
7. System will prompt the following message when there is default doctor’s signature is set
up in the system.
8. Click on button to save and load the doctor’s default signature – doctor will not need
to provide his/her signature.
9. Click on button to save without loading doctor’s default signature – doctor will have to
provide his/her signature to the consent form.
10. Use signature pad to sign. When all necessary signatures are available, system will
automatically finalise the consent form
2. Enter perform detail to the text editor OR use canned text for the entry
System will indicate the repeated order instruction in the procedure order
2. To start perform:
a. Click on button at the bottom-right corner of the order in Order Detail tile
At this step, status of the procedure will become Perform (I), with number of
perform made: 1/X where X is total times that the procedure needs to be
performed
1. Click on button.
2. When the order is repeated and it at least been performed once: system will prompt the
message
3. When the order has not been performed, system will prompt:
2. Select a charge set from dropdown list and click on button. Charge set components
will appear
4. To update the price rule: update the value in text box in respective record.
1. Click on button. System will display TOSP window. As default, system will
load the default TOSP setup
2. To add a TOSP
3. Click to select an available slot from the schedule. System will prompt
5. Click on button to save the booking. Else click on button to abort the action.
1.5.1.10 OP Nursing → OT
For operation, system provide separated screen.
3. Enter search criteria to search for package and click on buton. Search result will
appear
1. To do quick order:
a. Click on package icon at the top-left corner of each package tile
b. Package will be ordered and appear in timeline – with Order in-progress status
2. Order using order detail: click on each tile and system will display package component
window
c. Click to select the order, in-progress package in timeline. System will display
package detail
In here, icon is used to indicate that the service is post charge only and no
clinical workflow needs to be triggered.
2. Select doctor for each service order and store for each physical item using dropdown list
in each component if there is
3. Else, nurse can do mass initiate order by selecting doctor and store dropdown list on top
of the window, and click on button
4. Click on button (Initiate Order) located at the middle-left of the page. System will
prompt:
6. Upon confirmation, order detail will be automatically assign and patient will appear in
respective functions in other modules in order to perform the service
For services
For physical item: stock will be deducted – status will be “Dispense, F””
4. Click on buton. The service will be changed to Post charge – icon appears
3. Click on (Clinical) button. Initiate order button will appear on the left
4. Click on (Initiate) button. Then click on button to confirm. The order will be
triggered to clinical workflow.
3. Upon confirmation, system will close the package. Closed package will appear in
Closed/Finalized list
1. Select "Orders" tab. System will display all the current orders that are waiting to be
performed.
From left to right: Indicate lab / Indicate current status Roll mouse over
- Click to perform the order radiology order of each order to view order
- Delete order without performing priority remark
- Close performed order
The services are grouped by service type, with order information and its status. User
can:
Perform the service: perform ordered services.
Print the lab order form for lab services.
Close the order
Delete the order
2. Toggle the viewing of the orders between Outstanding, In progress and Performed
option.
Note: in Status column, system will display status of order - ORDER, F - to indicate the
service is ordered. The value in blanket after the status such as: (1/1), (1/3), (2/3), (1/4) is
used to indicate if the order is repeated or not.
For e.g.:
ORDER (F) (1/1) - indicate single order and no perform has been done yet. It is
required to be performed one time only.
ORDER (F) (1/3) - indicate the service is repeated order and no perform has been
done yet. It is required to be performed 3 times.
PERFORM (F) (2/3) - indicate the service is repeated order. It is performed 2 times
and required to be performed one more time to complete.
3. Current login user will be shown on the bottom of the screen (before the buttons at the
bottom-right of the page).
4. For lab services: click on button (next to section Lab Services) to print the Lab
Order Form.
Note: user can setup option to view before print and print direct and default printer for
direct printing of Lab Order Form in System Admin > System > Printer function: Label
tab, Label Type: LAB ORDER FORM.
c. Select reason
d. Enter remark
e. Click on button to confirm deletion. Else, click on button to abort the action.
f. If the service is billed, system will prompt:
1. Click on button in any lab order in Orders tab, system will display Take Sample
window
1. Click on button to perform the procedure. System will display a window to perform
all procedures in the waiting list.
Canned Text (bottom-left) - existing canned text can be used to enter perform
details.
Note: the canned text needs to be setup in Clinical Management > Maintenance >
Canned Text function, for Function - SERVICES.
Perform History (top-right) - to view perform history (normally used for repeated
order)
Perform Details (bottom-right) - to enter perform details.
Assessment History (below perform details section) - to enter assessment
history. This section is only be used for repeated order.
2. Select the procedure in Order Detail section at the top-left corner of the page.
Note: Canned Text needs to be setup in Clinical Mgmt Maintenance Canned Text, for
Function PATIENT ADVISE
a. Select re-defined patient advice from Canned Text section
b. The content will appear in the text editor
c. Update necessary information
d. Click on button
Patient advice from manual entry will appear in “Patient Advice” section while patient
advice from pre-defined documnt will appear in “Document” section.
Some icons are used:
Status of patient advice: - in-progress or - finalized
Icon - indicate advice that has consent.
Icon to indicate HCP type who added the advice: - doctor or - nurse
b. Enter consent information: using free text editor or using canned text
Note: canned text for consent needs to be setup in Clinical Mgmt -> Maintenance ->
Canned Text, for Function CONSENT PATIENT ADVICE
c. Click on button.
d. The section for the electronic signature will be enabled
i. If NOK signs the consent: Select next of kin from dropdown list
ii. If the NOK is not available, enter person information to ID*, Name*,
Address, Contact
iii. Click on the white area for signature or click on button to active
fingerprint feature
iv. Using signature device to sign and click on button
11. Click on button to finalize all orders made, clinical notes and billing charges.
12. System will redirect to the Nursing Queue List, to proceed with the next patient.
13. By default, system will display list of patients who are registered today's date.
15. Pick up the patient by selecting the record from the list.
16. System will redirect to patient's EMR screen. Refer to all sections from EMR section for
details steps.
1.6 IP Nursing
This function is similar to OP Nursing, with additional features as follows:
Write handover note
Record vital signs
Record intake and output
View discharge information
Record home drug
Order drug on behalf of doctor in-charge.
Drug administration
1. From Vesalius Home page, click on Nursing module icon and select IP Nursing
function. System will display IP Nursing - Queue List page, showing queue list in login
location by default.
2. The nurse/doctor needs to login first. If the user is an authenticated nurse, the system
will auto login this part for nurses only.
5. Once the login user is authenticated, a date/time stamp will appear with the user ID.
6. If the user has been idle since the last end session or exit for more than 3 minutes, the
system will force the user to re-login whenever he/ she tries to pick up a patient.
7. Enter the password of one of the previous users or enter with a new user ID and
password. Then click the button.
8. Else, click the button if the user does not wish to login.
10. Click to see the list of attending doctors. The one marked with a is the primary
attending doctor.
12. System will display a window for the user to enter hand-over notes.
Hand-over message
Handover notes,
after save
15. The following icons are actions which can be done from this screen.
Click to close the handover note*.
Refer to Handover Notes → Close a hand-over note section
Click to void the handover note
Refer to Handover Notes → Void hand-over notes section
16. Once the handover note is created, system will highlight the icon.
Current notes,
including Messages from
closed notes other users
Messages from
current user
Messages from other users are displayed on the left hand side
19. To create an entirely new handover note, the user must first close the previous note.
23. System will close the handover note and user will be redirected to the blank hand-over
note.
Note:
The closed notes will be saved in the menu on the left hand side
The user will not be able to add remarks under this handover title once closed.
To create the new hand-over note again, user will have to enter hand-over note title
and description as in Handover Notes → Create hand-over notes section.
27. System will display the content of void entries with strikethrough.
Voided note
Female patient
Male patient
Purposes
Click to create handover notes
Urgent orders (lab) waiting to be performed
Investigation orders waiting to be performed
Procedures waiting to be performed
Completed lab/radiology reports for doctor’s review
Click to view list of attending doctors
30. Select a patient from the queue by selecting the patient’s record. The system will
redirect to EMR → Facesheet.
32. Upon enable, system will redirect to "Orders" tab if the patient has any services ordered
which are waiting to be performed and display all tabs.
Common buttons throughout the Nursing session at the bottom-right of the page:
The button will exit from nursing session and direct the nurse to the Work List
queue.
The button will end the nursing session.
34. The Open Medication (bottom) section displays the dispense quantity and status of
medications with open instructions which are prescribed.
35. Click on icon in each medication to view dispense and return history of the drug.
System will display the Dispense History in a small window.
38. Click on the icon to select the I/O parameters to be used for the current patient.
39. Select the INPUT and OUTPUT parameters by checking the checkbox in front of each
parameter in the "Available Parameters" (left panel) and click on to move selected
I/O parameters to "Selected Parameters" (right panel).
Note: Use 2 buttons and to select/remove I/O parameters.
41. System will display selected I/O parameters in the I/O page
1 - Enter reading
date/time 2 - Enter value and remark
for each I/O parameter
42. To capture the I/O reading: user has to enter the following information:
a. Reading date/time (defaulted to current system date and time)
Note: user cannot enter future date/time
b. At least one field of input or output
c. Enter any remark for each parameter (if necessary)
d. Enter a general remark (if necessary)
44. User can create an entry as of the time that action is given to the patient, up to a back
dated time of 24-hours. However, the date and time should not be in the future.
45. When the reading is saved with a remark, it will be underlined. Click on the underlined
reading or click the icon (under Remarks field) to display the remarks.
46. Click on button to search all the entries including the last 24 or 48-hour reading. By
default, 24-hour is selected.
1.6.2.4 Vitals
The nurse can use this function to record the patient’s vital signs (e.g. Blood Pressure, Height,
Weight, Temperature, Pulse, Respiration, SPO2, etc)
(a)
(b)
49. Same as the I/O, the system will default to the current date/time. User can change the
reading date/time if required.
Note: System will check entered date and time
The reading date/time cannot be in the future. System will prompt:
The reading date/time cannot be earlier than 24 hours in the past. System will
prompt:
50. Enter necessary reading by entering value into each of the field in section (a).
(b)
52. Click on icon to display the readings in chart form. System will display a window with
the charting based on entries in the last 24 hours.
Note: User can view the chart for a particular date, from a specified time of the day, for x
number of hours. User only needs to select/enter the following fields:
Select the date
Time From
For field: number of hours from Time From field.
53. From the chart view, click on button to display the readings back in a tabular format.
55. From the main Vitals screen, click on button to view all of the readings. System will
prompt:
56. Click on button to confirm. Else, click on button to abort the action.
b. Click on icon.
c. System will prompt:
1.6.2.7 Care
The Care tab consists of two tabs:
Clinical Template – to enter nursing clinical templates. This function is same as
Template in Outpatient Nursing
Nursing Care Plan – to outline the nursing care to a patient. It consists of a list of
actions/ interventions that the nurse will follow.
63. Click on button. Care plan will appear in Selected Care Plan section (with status
Order, I)
67. To finalize the care plan - confirm that the care plan is going to be used:
a. Click on button. System will prompt:
c. Upon finalize, the status of the care plan will change from ORDER (I) to ORDER
(F).
68. Click the finalized care plan (ORDER, F status). The tasks of the care plan will appear
in the Care Plan Task section.
69. Check the checkbox of the task and enter a remark if necessary. Then click on
button to save each task.
Note: The date, time and user stamp will appear below the remarks field.
72. When the patient's session is ended, ( ), the care plan status becomes PERFORM (I).
The nurse can continue performing the tasks by repeat the process.
75. Click on button in each care plan to print respective care plan.
76. Click on button at the bottom of “Selected care plan” to print all care plan.
1.6.2.12 Services → IP AH
81. This tab is identical to Service - Allied Health (AH) section in OP Nursing function.
1.6.2.13 Services → IP OT
82. This tab is identical to Service - OT section in OP Nursing function.
1.6.2.15 Package
84. This tab is identical to Package section in OP Nursing function.
1.6.2.16 RX
The nurse can order medication (Rx) verbally for the inpatient using the Rx tab.
Verbal order is defined as an order spoken aloud in person or by telephone. This kind of order
most commonly originates from a doctor who does not have access to the system at that time,
to place the order on his/her own.
1.6.2.16.1 Order Rx
86. Select the doctor who will acknowledge verbal order.
87. Select or enter any of the following in the Rx Order section to search for drug:
Free text search
Class
Note: icon to indicate route of admin: - oral drug and - non-oral drug
89. The icon provides information on how to enter the instruction when ordering drugs.
b. Enter the instruction based on the template selected from the Usage column. The
system will automatically populate the quantity required if a calculated instruction
is used.
c. Enter any remarks (if applicable).
d. Click on button.
94. To view the intervention details of a drug if there is, click the icon located at the
lower-left corner of the screen.
95. Click on button located at the middle-left side of the screen to view the patient’s past
prescription. This will allow the user to order the same medication/s that were ordered
from previous visits.
98. Upon ordering, the system will check following patient safety and prompt the Patient
Safety Alert window if there is:
Patient is allergic to medication ordered
Medication is contraindicated to patient's medical condition
Medication ordered has a drug to drug interaction
Medication order exceeds maximum dosage
The overriden order will be marked with a icon. Roll the cursor over this icon to
see the tooltip - "Order by Nurse with Override".
101.Select the retail item(s) to be added and key in the instruction or quantity for the
selected item.
102.Click on button to add the retail item. The order will appear.
1.6.2.17 Disposition
108.To print the issued MC: click on button to print out the MC.
110.To print the issued time chit: click on button to print out the time chit.
114.Click on button to finalize all orders made, clinical notes and billing charges.
115.System will redirect to the IP Nursing Work List to proceed with the next patient.
119.Refer to IP Nursing → Work List section to perform steps after selecting patient.
121.System will display patients with expected arrival date which fall on or in between the
searching criteria.
Note: If the login location is a ward location, system will automatically filter the list by
ward.
124.Refer to IP Nursing → Work List section to perform steps after selecting patient.
126.To search for patient: enter the following search criteria in the Medication Administration
section.
PRN
Name
Ward
Bed No
Date/Time - default to current date and time. System will high-lighted the time
range that displayed date and time is falling to.
(2) Patient name/Bed location (1) The administration slot covers 24 hr period
24 Hrs
(3)
(6)
(1) -The administration slot covers 24 hr period, which is divided into 4 time zones,
each of 6 hours interval.
(2) - Patient name/ PRN/ Bed No
(3) - Displays the instruction and the default time slot to serve drug according to
instruction given
(4) - Displays in 2 respective lines:
Line 1: Served: is served quantity – quantity which patient consumed
Line 2: Dispense/Home: displays total dispense quantity / quantity which
patient brought from home
(5) - To shift the time to serve drug (refer to IMR → Shift administration time slot
section)
(6) - Displays legend which indicate the status of drug administration in (3)
The last row in the each item description - Displays the ordering doctor name
129.Click on the patient’s due time slot ( ) – represented in yellow color with the timing.
130.The screen will display serving screen based on system parameter setup
Note: There are 2 parameters that indicate whether the function needs to verify patient
and drug during drug administration. These are:
DRUG_ADMIN_ITEM_CHECK: if it is set as “Y”, the function will prompt to enter
drug code and display image of drug (if available) once correct drug code is
entered.
DRUG_ADMIN_PATIENT_CHECK: if set as “Y”, the function will display image of
patient (if available) once correct PRN is entered
a. If both parameters are set to “N”: images of patient and drug will appear
b. If both parameters are set to “Y”: 2 more fields appear for user to enter
o PRN
o Drug code
c. If either one of the parameter or both are set to “Y”, system will require data
checking entered by the user.
ii. icon: if the PRN is correct, and system will display the patient’s photo
(if the photo is available).
134.System will populate the date/time for the rest of the field:
a. Suggested Date/Time: display the serve time according to the setup from system
Note: The setup is at OP Pharmacy > Maintenance > Dosage Instruction function >
Drug Frequency tab.
b. Date/Time: actual date/time that the drug is served
c. Serve By: displays current user logged in to the IP Nursing function
135.Click on button to save the information. The time slot will be updated to and
served quantity will be updated accordingly.
Note:
Only served slot can be voided when applicable
Void reason could be setup at: System Admin > Common Admin > Reason: reason
type: "MEDICATION ADMINISTRATION VOID REASON”.
140.The time slot will be updated to and served quantity will be updated accordingly.
Note:
Served quantity will not change.
Omit reason can be setup at: System Admin > Common Admin > Reason funciotn,
reason type: "MEDICATION ADMINISTRATION OMIT REASON"
i. Click on or icon which appear under each time slot to move back /
forward one-hourly.
ii. The time displayed inside the time slot will change by 1 hour.
iii. The color of the time slot will change accordingly - due (in yellow) or
planned (in blue).
iv. Enter remarks if required
v. Click on button to save or click on button to go back to IMR
screen.
i. Select the check box "Shift Half Hour" to indicate shifting by half-hour
interval
ii. Click on or icon which appear under each time slot to move back /
forward half-hourly
iii. The time displayed inside the time slot will change by half an hour.
iv. The color of the time slot will change accordingly - due (in yellow) or
planned (in blue).
v. Enter remarks if required
vi. Click on button to save or click on button to go back to IMR
screen.
i. Select the check box "Shift Half Hour: to shift by half-hour interval
ii. Click on or icon to move back / forward ALL time slots by half-
hour.
iii. The time displayed inside all slots will change by half an hour.
iv. The color of the time slot will change accordingly - due (in yellow) or
planned (in blue).
v. Enter remarks if required
vi. Click on button to save or click on button to go back to IMR
screen.
i. Select the check box “All Future Days” to save the modified timing for the
current and succeeding days. This checkbox is only enabled for the
current day and T+1 (next day).
ii. Proceed as normal in shifting individual or all slots by half-hour or one-
hour interval.
iii. Click on button to save or click on button to go back to IMR
screen.
150.The time slot(s) will be updated to the shifted time in the IMR screen.
153.Enter patient PRN and/or item code for patient and/or drug verification if there is.
(a)
(b)
161.Click on (view detail for this order) button at the individual drug record to view details
for this drug only.
162.Select the drug record in section (a), chose the type ‘in’ or ‘out’, enter the quantity and
remarks, if any.
The type ‘In’ is for receiving drugs brought by patient. This will increase the
quantity of the home drug.
The type ‘Out’ is for returning drugs to the patient. This will reduce the quantity of
the home drug.
163.Click on button.
Note: The status for a receive (IN) is ORDER (I) while the return (OUT) is RETURN (I).
1.7 Perform DI
Nurses can perform diagnostic investigation service using this function.
1. From Vesalius Home page, click on IP Nursing module icon and select Perform DI
function.
2. System will display list of patients who have diagnostic investigation service orders
and waiting to be performed.
5. Select the patient from the list. System will redirect to Reporting screen: Detail tab >
Reporting tab:
7. Once the DI order is selected, the Canned Text section will populate available canned
texts.
Note: Setup the canned text in Clinical Mgmt > Maintenance > Canned Text function,
Function: Perform DI.
9. To enter report using text editor: update the content in the "Reporting" section.
Note:
User can use the formatting tools in the editor to format the report content.
To avoid unwanted content or breakable content in the report, user is strongly
advice NOT to copy and paste the content from any rich text format document
(word, excel, web page, etc...). User should copy the desired content to Notepad
program first, then copy to the editor and format using provided tools.
12. Once the report is saved, system will update status of ordered DI service with In-
progress icon - .
14. Select the template from the Template List section. Selected template content will be
populated to the right side of screen.
25. Click on button to add a new image upload and repeat steps to update more
images.
1. From Vesalius Home page, click on IP Nursing module icon and select Manage BTS
function.
10. System will display Manage BTS screen - RCV column will be marked with a icon.
16. Select a template from the templates list (if necessary) and fill out the applicable fields.
20. Click on button to proceed. Else, click on button to abort the action.
21. System will close the perform detail screen and re-directed to the Manage BTS main
screen. The PFM column will be marked using button - finalized.
23. Click on button to close the window. The user will be directed back to the Manage
BTS screen.
25. The RCV column will be marked with a icon (done) and the both PFM and RTN
column has button appearing (not done).
26. Click on button in RTN column. System will display "Manage BTS - Return" window:.
Note: The "Used" field will has “No” value since the transfusion has not been performed
and the blood has not been used.
28. Click on button to save. Otherwise, click on button to close the window.
29. After saving, the user will be directed back to the Manage BTS screen with the icon
under the PFM and RTN columns deactivated.
Note: User can perform the "receive blood" step again.
30. The RCV column will be marked with the icon (done) and the PFM column will be
marked with the button(done). The button in RTN column will be activated.
31. Click on button in RTN column. System will display "Manage BTS - Return" window:
Note: The Used field will be a “Yes” since the transfusion has been performed and the
blood has been used
33. Click on button to save. Otherwise, click on button to close the window.
34. After saving, the user will be directed back to the Manage BTS screen. The patient
record will be removed from the list.
1. From Vesalius Home page, click on Nursing module icon and select Manage Package
function.
5. The Manage Package screen will appear with previously ordered package (if any) in
the List of Ordered Packages section.
9. Select the package to be ordered from the search result. Services and items inside the
package will appear on the right panel.
11. Ordered packages will appear in the List of Ordered Packages section.
Note:
Icon indicates that the package status is now in-progress. User can delete or
finalize the package.
Icon indicates that the package status is finalized. User can delete or close
the package under certain condition.
Select the check box to view all packages (active/closed)
that have been ordered for the patient.
15. After delete / close: ordered package will be removed from default List of Ordered
Packages section.
17. Select the finalized package: package's components will be displayed in "Package
Items" section.
Dispense physical item: user will need to assign the store where the item will be
deducted from. The stock levels of that store will be reduced.
Post charge service: non-clinical workflow will be involved. The service in the
package are strictly for charging purpose.
There are 2 methods to initiate order for package’s component – either to follow
clinical workflow or post charge:
Individual initiate order: to initiate, dispense or post charge single package item
Mass initiate order: to initiate or dispense for all package items at one time
a. Click on button.
b. The button will change to . This will initiate the clinical order/s. If the
Laboratory and Radiology modules are installed, a linkage to the respective
modules will be created.
c. Click on button to confirm the action.
d. The user will be directed back to the “Manage Package” screen. The initiated
clinical order will display the saved information and its status.
Note: The status of the clinical order will be ORDER (F).
24. Click on button to set the clinical order package item as a post charge item.
26. The user will be directed back to the Manage Package screen. The clinical order which
was changed to a post-charge item will be marked with . This icon denotes that the
item is a charge-only order.
28. Click on button located at the bottom-left corner of the page (after - “Back”
button).
29. System will display window to mass initiate orders:
30. For service items: nurse can apply same doctor to all the service items
a. Select the doctor from Doctor dropdown list.
b. Click on button next to the doctor list to populate the same doctor to all
services
c. Selected doctor will be applied to all the service items in the Outstanding Order
section.
d. If any of the service requires a different doctor, user can still change by
selecting a different doctor from the list in the respective row.
31. For physical item: nurse can select same store that all physical items inside the
package will be deducted from
a. Select the store from Store dropdown list.
b. Click the icon next to Store field.
c. System will update the store for all the outstanding physical item orders.
d. If any of the items are deducted from other store, user can still change by
selecting a different store in the respective row
35. Select the package to from search result. Package details will appear on the right
panel
37. Select future option: DATE or NEXT VISIT (a date is required if user select DATE
option)
39. Click on button to order package. The order will be ‘In-progress’ and appear in "List
of Future Packages" section.
40. Select a record in future package section and then button and button will be
enable.
43. To finalize future order: click on button Status of future order will be finalized
Note: future order has to be finalized before user can convert it in the next date/next visit
45. To view package details - at the time package was ordered: click on button.
System will display package details at a time it was ordered from previous visit and
current package details. Information is display in a pop-up window.
Note: If there is no difference, the package can be converted to current order. Otherwise,
re-order the package in current visit is required.
47. Upon confirmation, the package will appear in "List Of Ordered Packages" section -
status "In-progress".
1. From Vesalius Home page, click on Nursing module icon and select Manage HCU
function.
2. System will display Manage HCU main page that include list of current HCU patients
4. The following icons will indicate the current status of the patient. The possibility to
reassign the patient is also noted.
Patient is waiting in primary Able to reassign
consultation queue
Consultation session in Not able to reassign
progress
Consultation is halted pre- Able to reassign
maturely
Patient has no outstanding Able to reassign
queue
5. Click any of the 4 icons above to see the list of doctors and its status to the patients.
d. Click on radiology button in front of the doctor to select a doctor from the list.
e. Click on button. Else, click on button to close the window.
8. After selecting the doctor, the system will populate the full name of the doctor in the
Next Doctor field.
Note: For those in-progress sessions, system will not allow the user to do reassignment.
2 MAINTENANCE
The vital sign that requires input needs to be linked to Clinical Measurement service defined in
Service Master in order to make the vital sign available for the nurse to use.
1. From Vesalius Home page, click on Nursing module icon and select Vital Signs
function. By default, the system will display all available vital signs.
2. The icon denotes that a vital sign is linked to a service. Once the user mouse over
the icon, the service name linked to it will appear.
Vital Code*
Vital Description*
Sequence
Min Value
Max Value
Vital Group*
Inactive Date
Include in Chart
Line Color
Point Type
6. Click on button.
Note
A vital sign used in a formula is only available after saving.
Syntax for keying-in the formula:
oTo use a vital sign value as a parameter, use ‘#’ with the vital sign
code, follow by ‘VALUE#’. The # must be put in front and at the back
of the code. E.g. #HT.VALUE1#
oOperator value allowed are +, -, *, /
oIf vital code (defined in Clinical Measurement item) used for the
calculation has multiple values, the format for the value is
#CODE.VALUE1#, #CODE.VALUE2#
Example:
BMI = Weight/(Height*Height)
The formula for the BMI = #WT.VALUE1#/(#HT.VALUE1#*#HT.VALUE1#)
8. Select a vital sign to be deleted by clicking on the record from the main screen.
10. Click on button to confirm deletion. Else, click on button to abort the action.
13. Select the Vitals Code from the list to link it to the corresponding Vital Sign.
16. User will display "Vitals Chart Group" window (existing vital chart groups will be
displayed if there is):
17. In "Vital Chart Group" window: enter the group information (* - mandatory):
Code*
Description*
Display Order.
Note: newly created vital chart will have blank value in Vital Description column.
21. Click on button in the vital group record to add/remove vital signs to/from vital
group. System will display a window:
The name of selected vital group will be displayed on top of the window, in the
middle
Available Vitals (left) - available vitals which are not yet appeared in any vital
group
Selected Vitals (right) - selected vitals in current vital group.
b. Click on button.
c. Selected vitals will be moved to "Selected Vitals" section on the right.
b. Click on button.
c. Selected vitals will be removed from "Selected Vitals" section on the right.
25. The Vital chart group will display the description with list of selected vitals on screen.
26. Click on button in each row in "Vital Description" column to remove the vital from
the chart.
28. In "Vital Chart Group" window: enter the group information (* - mandatory)
Code*
Description*
Display Order.
Check "Two Y-Axis" checkbox
Select Y-Axis (L) color* from dropdown list to define the color of chart for the
LEFT Y-Axis.
Select Y-Axis (R) color* from dropdown list to define the color of chart for the
RIGHT Y-Axis.
29. Click button. New group will appear - with icon to indicate two Y-axis vital chart
group.
b. Click on button
32. Click on button to add/remove vital signs to/from selected vital group. System will
display a window
b. Select option from the dropdown list: Left or Right to indicate the Y-axis for
each selected vitals.
c. Click on button.
d. Selected vitals will appear in "Selected Vitals" in the right section. The vital
signs will be displayed in two column based on selected option, with color
coded for each Y-axis.
b. Click on button.
c. Selected vitals will be disappear.
36. The Vital chart group will display the description with list of selected vitals on screen.
37. Click on button in each row in "Vital Description" column to remove the vital from
the chart
1. From Vesalius Home page, click on Nursing module icon and select I/O Parameters
function. Current I/O parameters setup will be displayed on the screen.