Electronic patient records
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Recording Triage Episodes on Computer: Step-by-Step Guide
Introduction to Triage Recording
Mark and Shawn discuss the process of recording triage episodes electronically:
- Initial Steps: Introduce yourself to the patient, take physical observations, and gather history of complaints.
- Accessing Triage Details Tab: Navigate to the triage details section on the computer system.
- Data Entry: Enter date, time, and personal details followed by patient's physical observations.
Entering Vital Signs
Shawn demonstrates entering vital signs into the computer:
- Example 1 - Stable Patient: Respiratory rate 16, oxygen saturation 98%, temperature 36.8°C, systolic blood pressure 124, heart rate 68, pain score 2, alertness.
- Example 2 - Acutely Unwell Patient: Respiratory rate 38, oxygen saturation 91%, temperature 36.6°C, systolic blood pressure 120, heart rate 38, pain score 0.
Automatic Calculation of NEWS Score
Mark learns about the automated calculation of NEWS score based on vital signs:
- NEWS 2 Calculation: The computer computes the NEWS score automatically from entered vital signs.
- Example of Acute Illness: High NEWS score indicates severe condition prompting immediate action to transfer to resuscitation area.
Understanding and correctly entering triage data ensures efficient patient management and appropriate medical response.