Enter/Edit Patient Data (PDS / e-Kardex)

What does PDS stand for in this presentation?

Patient Data System.

What is another name for Enter/Edit Patient Data at some sites?

e-Kardex.

What information can be entered through Enter/Edit Patient Data?

Diagnosis, height, weight, infection control information, temporary location, allergies, and condition details.

What identifiers can be used to search for a patient in Enter/Edit Patient Data?

Account number, PHN, MRN, or name.

How should you search for a patient?

Use one patient identifier at a time.

What happens after selecting the correct patient?

The patient information screen displays.

What is the purpose of the Temporary Location field?

To provide access to the electronic record when a patient transfers departments.

What should be entered in Temporary Location when a patient transfers departments?

The receiving department's location.

How may some locations automatically populate in the Temporary Location field?

Using the two-letter facility prefix.

What is the Condition field used for?

Patient inquiry by non-clinical staff.

How do you look up a condition?

Press F9 to open the lookup menu and select the applicable auto-populated condition.

What is the Condition Comment field used for?

General information for visitors.

How should the Condition Comment field be completed?

Enter appropriate free text without including condition details or diagnosis.

Why must diagnosis and condition details be excluded from Condition Comment?

To maintain patient confidentiality.

What does the Visitors Allowed field indicate?

Whether visitors are allowed, using Y or N.

How do you find available Visitors Allowed options?

Press F9 when needed.

Who enters the Visit Reason field?

Registration only.

Can a Unit Clerk enter a patient's height and weight?

Yes.

What should you check before entering height and weight?

Select the correct measurement system.

What does BSA stand for?

Body Surface Area.

How is BSA calculated in Enter/Edit Patient Data?

It calculates automatically after height and weight are entered.

Why are height and weight important?

They support transport, diagnostic testing, and pharmacy workflows.

What are examples of Custom Queries in Enter/Edit Patient Data?

Critical Care Indicators, diagnosis, language, MOST, infection control, and allergies.

How is a CCI entered and processed?

It is placed through Order Entry and processed by Registration / Health Records.

When can the diagnosis be updated?

Once the medical diagnosis is known.

How can the patient's language be looked up?

Press F9 when translation is required.

When does MOST display in the patient data screen?

When Order Entry has been processed.

Where can a signed MOST be found?

In a green sleeve at the front of the patient's chart.

What does the Custom Queries screen allow the Unit Clerk to enter or review?

Estimated discharge date, infection control information, screening answers, and surgery/procedure information.

Is the Estimated Discharge Date mandatory?

No. It may be entered if known.

Which field is mandatory on the Custom Queries screen according to the presentation?

Infection Control.

What healthcare-related screening questions are included in Custom Queries?

Whether the patient has been admitted to a hospital, care home, dialysis facility, correctional facility, or shelter in the last 6 months, and whether they have had a healthcare encounter outside Canada in the last 12 months.

Who obtains missing screening information when it is not available from Registration?

The Unit Clerk.

What should be done with Surgery / Procedure information if none is present?

Update it if no information is present.

Who updates drug allergies?

Pharmacy.

Can Unit Clerks enter food allergies?

Depending on the unit or facility, yes.

What should a Unit Clerk do before entering food allergy information?

Check the unit/facility's data-entry process.

How do you save completed patient data changes?

Press F12 or select Save.