Nurse Guide

As a nurse using SecureHealth, you have access to patient medical data and care coordination tools. This guide will help you navigate the system efficiently while maintaining HIPAA compliance and providing optimal patient care.

Nurse Dashboard Overview

The nurse dashboard provides access to:

• Patient Care: Medical data and patient care information
• Care Coordination: Manage patient care plans and activities
• Medication Administration: Record medication administration
• Communication: Communicate with doctors and other staff
• Limited Personal Data: Access to necessary patient demographics
• Care Documentation: Document patient care activities

Patient Care Management

Accessing Patient Information

Patient Search

1. Use the search bar to find patients
2. Enter patient name, ID, or other identifying information
3. Review search results
4. Click on patient to view medical information

Patient Overview

• Demographics: Name, DOB, contact information
• Medical History: Relevant medical information
• Current Medications: Active prescriptions and dosages
• Allergies: Known allergies and adverse reactions
• Care Plan: Current care instructions and goals

Medical Data Access

Available Information

• Medical History: Past diagnoses and treatments
• Lab Results: Blood tests, imaging, pathology reports
• Vital Signs: Blood pressure, heart rate, temperature
• Progress Notes: Clinical notes and observations
• Treatment Plans: Current and past treatment plans

Restricted Information

• Personal Financial Information: Not accessible to nurses
• Administrative Data: Not accessible to nurses

Care Plan Management

Viewing Care Plans

1. Access patient record
2. Click "Care Plan"
3. Review current care instructions
4. Check care goals and objectives
5. Monitor progress toward goals

Updating Care Plans

1. Go to patient care plan
2. Click "Update Care Plan"
3. Add new care instructions
4. Modify existing instructions
5. Document care activities
6. Save changes

Medication Administration

Medication Management

Viewing Medications

1. Access patient record
2. Click "Medications"
3. View current prescriptions
4. Check medication schedules
5. Review administration instructions

Medication Administration

1. Go to patient's medication list
2. Select medication to administer
3. Record administration details:
   • Time of administration
   • Dosage given
   • Route of administration
   • Patient response
4. Document any adverse reactions
5. Save administration record

Drug Interaction Checking

Check Interactions

1. Select patient's current medications
2. Review interaction warnings
3. Check severity levels
4. Document interaction assessment
5. Report concerns to doctor

Interaction Types

• Major: Significant risk, contact doctor immediately
• Moderate: Moderate risk, monitor closely
• Minor: Minor risk, minimal monitoring needed
• Unknown: Insufficient data, use caution

Care Coordination

Patient Care Activities

Daily Care Tasks

1. Review patient assignments
2. Check care instructions
3. Perform care activities
4. Document care provided
5. Update care status

Care Documentation

1. Access patient record
2. Click "Care Documentation"
3. Select care activity type
4. Enter care details
5. Document patient response
6. Save documentation

Communication with Doctors

Patient Updates

1. Go to Staff Communication
2. Select doctor from team list
3. Send message about patient care
4. Include relevant patient information
5. Set priority level
6. Send message

Communication Types

• Patient Status Updates: Changes in patient condition
• Care Concerns: Issues requiring doctor attention
• Medication Issues: Problems with medications
• Care Questions: Questions about care instructions

Team Collaboration

Shift Handoffs

1. Access shift handoff tool
2. Review patient information
3. Document care activities
4. Note any concerns
5. Complete handoff documentation

Multidisciplinary Rounds

1. Participate in team rounds
2. Provide patient updates
3. Discuss care plans
4. Coordinate care activities
5. Document decisions

Care Documentation

Documenting Patient Care

Care Notes

1. Access patient record
2. Click "Add Care Note"
3. Enter care observations
4. Document care activities
5. Note patient response
6. Save note with timestamp

Note Types

• Assessment Notes: Patient assessment findings
• Care Notes: Care activities performed
• Progress Notes: Patient progress updates
• Incident Notes: Unusual events or incidents

Vital Signs Documentation

Recording Vital Signs

1. Go to patient record
2. Click "Vital Signs"
3. Enter current vital signs:
   • Blood pressure
   • Heart rate
   • Temperature
   • Respiratory rate
   • Oxygen saturation
4. Document any abnormalities
5. Save vital signs record

Vital Signs Trends

• View vital signs over time
• Compare with previous readings
• Identify trends and patterns
• Report significant changes

Patient Safety

Safety Protocols

Patient Identification

1. Verify patient identity
2. Check patient ID band
3. Confirm patient name and DOB
4. Use two patient identifiers
5. Document verification

Medication Safety

1. Verify medication order
2. Check patient allergies
3. Confirm medication details
4. Use medication administration record
5. Document administration

Incident Reporting

Reporting Incidents

1. Access incident reporting tool
2. Select incident type
3. Enter incident details
4. Document patient impact
5. Submit incident report

Incident Types

• Medication Errors: Incorrect medication administration
• Patient Falls: Patient fall incidents
• Equipment Issues: Equipment malfunctions
• Safety Concerns: General safety issues

Compliance and Audit

HIPAA Compliance

Patient Privacy

• Only access patient data when necessary
• Maintain patient confidentiality
• Use secure communication methods
• Document access appropriately

Data Security

• Use strong passwords
• Log out when finished
• Report security incidents
• Follow security policies

Audit Logging

Access Monitoring

• Your access to patient data is logged
• Audit logs track all patient interactions
• Compliance monitoring is automatic
• Access patterns are monitored

Best Practices

Patient Care

Documentation

• Document all patient interactions
• Use clear, concise language
• Include relevant medical information
• Maintain accurate records

Communication

• Communicate clearly with patients
• Explain care activities
• Answer patient questions
• Maintain professional relationships

System Usage

Efficiency

• Use search functions effectively
• Organize patient information
• Update records promptly
• Use templates when appropriate

Security

• Protect patient information
• Use secure passwords
• Log out when finished
• Report security concerns

Troubleshooting

Common Issues

Patient Search Problems

• Check spelling of patient name
• Try alternative search criteria
• Contact IT support if needed
• Review search help documentation

System Performance

• Check internet connection
• Clear browser cache
• Restart browser if needed
• Contact IT support for persistent issues

Access Problems

• Verify user account status
• Check role permissions
• Contact administrator
• Review audit logs

Getting Help

Documentation

• Review user guides
• Check troubleshooting guides
• Consult system help
• Access training materials

Support

• Contact IT support
• Escalate technical issues
• Request additional training
• Report system problems

Nurse Checklist

Daily Tasks

• Review patient assignments
• Check care instructions
• Perform care activities
• Document care provided
• Update care status

Weekly Tasks

• Review patient progress
• Update care plans
• Communicate with team
• Review audit logs
• Participate in rounds

Monthly Tasks

• Review patient outcomes
• Update care knowledge
• Participate in training
• Review compliance status
• Evaluate care processes

Next Steps

• Receptionist Guide - Receptionist workflows
• Patient Portal - Patient self-service
• Developer Guides - Technical implementation details
• Tutorials - Step-by-step implementation guides