Electronic patient records

So how do we record a triage episode on the computer?

Okay, Mark, so we have already introduced ourselves to the patient, we have started taking the physical observations, and we have got a brief history of the presented complaint and the chief complaint. We will select triage details tab there, and this will bring up another screen there. We need to populate the date and time screen, we need to put our own details into there as well. The important bits then when we have entered that, is entering the patient's physical observations. So we determined that the patient we have just assessed had a respiratory rate of 16, their oxygen saturations are 98%. They were on no oxygen, their temperature we recorded at 36.8, their systolic blood pressure reading was 124. They had a heart rate of 68, they had a pain score of two, and they were alert. Computer then will convert this into a NEWS 2 score, and this NEWS 2 score for this patient will be a zero given the observations that we have entered.

Okay.

And then when we scroll down to the early warning score, it has populated it as a zero there.

So the computer calculates the NEWS score from the vital signs that you input.

Automatically. Yeah, we do not input the NEWS score, the computer works it out itself.

Okay. So if a patient comes in and they are acutely unwell and they are generating abnormal vital signs, how does the computer interpret that?

Well, I will show you Mark. So once again, select the triage details tab, enter the date and time of the entry, put your own details down, and then we will put in the patient observations. Okay, so we have assessed a patient who has presented acutely unwell, came in with shortness of breath, looked unwell in the triage room, and when we assessed the patient, got a respiratory rate of 38, had oxygen saturations of 91, and this patient had no respiratory history at all. He was not on any oxygen. His temperature was 36.6, his systolic blood pressure was 120... His systolic. Okay. And he had a heart rate of 38. Okay, with a pain score of zero.

Now, straight away, we can see both on the screen and physically looking at the patient, this patient is acutely unwell. Straight away we know he has got a respiratory rate in excess of 25, so that is a score, a NEWS score of three straight away. His oxygen saturation is on 91%, so that will give us a NEWS score of a three. So we are on a NEWS score of six straight away, and he got a heart rate of 38, so an absolute bradycardia of three. This patient has actually got a NEWS score of nine now. This patient is acutely unwell, and we should have spotted this before we actually entered these details in. This patient needs removing straight round to resuscitation area with an alert message.