Documentation on TRAK

To create a nursing admission

Step 1. Select Patient on the Ward Floor Plan and choose EPR.

Step 2. From the Overview/Progress tab, choose Consultation List tab and click New.

Step 3. Enter password and click update.

Step 4. From Category choose Nursing Admission (N), Care Provider choose Nurse (N).

Step 5. Untick the checkbox on the right hand side to show all previously completed questionnaires.

Step 6. Complete the following questionnaires on the left hand side:

• Admission Details - ensure name, address and NOK details are accurate.
• Observations, Measurements and Near Patient tests – record height and weight plus any other applicable tests or measurements. It’s important to do this before the PCCP so that the height/weight/BMI can pre-populate into the risk assessments e.g., MUST, Waterlow.
• Person Centred Care Plan (PCCP) (including top boxes!) - complete all of the risk assessment questionnaires as you go through (list below).
• Adult Personal Care and Social Enquiry - this helps figure out the level of assistance the patient requires and also highlights issues for discharge planning.
• Required Risk Assessments –
  • 4AT
  • Additional risks (name band, allergies)
  • Bladder and bowel
  • Falls
  • Mobility
  • Oral hygiene
  • MRSA
  • MUST
  • Nutritional profile
  • Waterlow
  • (Others may also be applicable e.g., Pain, PVC or indwelling catheter).

Step 7. To save full Nursing Admission, click update.

Step 1. Select Patient on the Ward floor plan and choose ATD Menu then Dsch.

Step 2. Click update.

Step 3. 

Step 4.

Step 5. Input Discharge To. Click on the magnifying glass for options e.g., H=home.

Step 6. Click update.

To record on TRACK that a patient has died, on Discharge Type and Discharge To, input shortcut died then update as you would normally when discharging a patient.

The outcome of the risk assessments determines the frequency at which they need to be reviewed/updated. Eg. Waterlow score of over 15 should be reviewed daily, and 10-15 should be reviewed every 3 days. TRAK will pre-populate the appropriate date in the review box.

Look out for the red hourglass icon on the ward floorplan which indicates if a risk assessment is outstanding or due to be updated. 

To update risk assessments:

1. Click on the hourglass icon in the patient’s bedspace.
2. Type your login details in the boxes and Update.
3. Scroll down to the list of risk assessments and select the one(s) that require updating.

OR

1. Update using the links within the Person Centred Care Plan (PCCP).
2. PCCP must be filled in for all patients.

For all elective patients attending CAU, record their attendance details by writing an inpatient discharge summary in the Discharge Letter/Meds section on TRAK by using \eccacd.
[This includes patients attending for pre SACT blood tests and pump disconnects]
No other documentation is required.

How?

Highlight patient

Click EPR

Discharge Letter/Meds (on left hand side)

Correspondence - New

Note Type – Click magnifying glass, on drop down menu select Inpatient Discharge summary.
Enter: \eccacd (then press the space bar).

Headings will appear which need completed.
The entry below should not be changed only added to:

Once you have completed it, scroll down to:
Send electronically to GP - Yes
Change Status to authorised
Tick Finished and Ready for Coding

To use the following shortcuts whilst writing notes on TRAK, type required shortcut then press space bar.

Please note that the table below may need to be scrolled horizontally or vertically in order to view all information, depending on your device.