This article covers the use of the medication tracking feature in nurse documentation in EncaptureMD. It is typically used in invasive/interventional apps.
This article assumes the Medication Manager (Admin function) was used to initialize and define an app-specific medication set. If a medication is missing or not set up properly, ask an administrator to modify the medication set.
Overview
The Medication I/O case tracking is usually found along with the nurse's procedure log. It is divided into 4 sections - output, continuous infusion, single dose and input.
Information entered into these sections will appear in the procedure log and also as tables in the final report. Total Current I/O appears near the top (1) of this section. Show meds from all views (2)allows the user to see pre procedure and recovery medications when those views are used.
Every row in this section can be edited by double click. The rows can be re-ordered by adjusting the times. If the continuous infusion time is adjusted, the total dose and I/O will adjust accordingly.
I/O Log
Clicking the I/O Log button shows a table with the current I/O calculation for the case.
Output
To add a fluid output, click the +Output button, select a time, type of output and amount and click OK. the choices for output are customizable in the med manager. Once a row is added, it will appear on the right and can be edited by clicking on the row.
This section is often estimates vs ml-specific values.
Continuous Infusion
A continuous infusion is a medication given over time using a medication pump. For bulk administration (e.g. a hanging bag of fluid without a pump or an irrigation fluid) where the rate or the total is estimated, use the Input section below.
A medication Template is configured in the manager and includes the name of the medication template plus additional information depending on the type of infusion. It is possible to have more than one template for a medication that would vary based on route of administration, dilution or rate.
A continuous infusion can be edited by clicking on the row. The dose can be changed or the med can be stopped and restarted. From the main form, this can be done for the selected med or for all meds (1)
Fluids and medication templates
A template has a name, an associated medication, a med class an NDC number.
An infusion is based on a template and also defines who ordered and delivered it, the scribe who recorded it, any comment or notes and documentation the drip was running on arrival.
There are two different types of medications. If the med is just a fluid (e.g. normal saline, D5W) with no diluted medications, it has a pump rate and a selection for KVO (1).
If it is a medication (2), it has a drug dose, a dilution and dilution fluid, a pump rate and a selection for KVO.
Editing a running drip
Double click on an existing row in the Continuous Infusion table (above). Or Right click and choose Edit. The main window below opens. The pump rate can be changed. Edit the Pump rate or select KVO(1) and click the Change button (2). A new row will appear in the table below (3). The drip can be stopped and re-started using the Stop | v button (4).
The user can also double click on an existing row to open an editor (5) and edit there and click OK. Any change will add a new row to the table (6). A row can be deleted by clicking the Delete Last Row button (7).
No matter what changes are made including adjusting start and stop times, changing pump rate, etc the amount of fluid/medication given will be accurate and the medications in the procedure log will be updated accordingly and I/O will be accurate.
Exiting a study
If a drip is still running and the user closes the studies, the user must decide what to do with the drip. There are 3 options:
- Stop the infusion
- Continue the infusion/Ignore - when the drip continues to run, there is more than one nurse in the case, the present nurse is switching to a different workstation.
- Cancel - prevents the study close. User can go back and manually manipulate the drips in the meds tab.
Single Dose
Single dose meds are one time doses which can be given immediately or over a short period of time. If the drug is diluted or a pump is used, a continuous infusion is probably better.
Click +Single Dose (above) and this screen will pop up. Pick a drug template (1), dose, and if desired a given over period and time unit (sec/min). The Template defines the medication, med class and can define the dose, route or given over values. Even if defined, the user can adjust the dose, route or given over values.
Ordered by and Given by must be filled out. Once done, click Save to add just one drug or Save & Add to add another drug (2).
Input
Use input for fluids where precise values are not known. Irrigation, ablation cooling fluids, gastric/oral administration, etc. Choose the time, input and amount.
