5Tracker Orientation EDM Tracker Location Tracker (Main ED, Fast Track, etc.)These tracker are meant to be Standard Across the system.My RN TrackerThis tracker allows you to keep track of only patients you are caring for. It also shows more detailed information.Charge RN TrackerThis tracker will display all area’s of the ED and show more detail on the patient.
9Reception RoutineThis routine is the quickest way to get the patient on the tracker.It consists of only 4 required questions.Patient Name is a required field and should be entered in mixed case (ex. Darling, Jean)Routine is meant to be used by Nursing only if Patient Access/Registration is not available to put the patient on the tracker.Primarily this is a patient access/registration routine.Through this routine you are able to print the patient wrist band and face sheet.When RN’s must perform this routine they should enter the SS number whenever possible and click SEARCH for the MPI (master patient index).
12Triage and AllergiesTriage can be accessed through the tracker
13Triage and AllergiesThis routine allows you to document the Triage assessment as well as:Change the Location of the patientChange the Room for the patientEnter in the Patient’s Chief ComplaintThere are certain functions that even though you have access should not be updated on this screenFilling in the Providers of Care will update the statistics such as door to doctor time. This is being updated another way and should not be updated on this screen.The only fields that should be filled in on the screen in the first tab of the screen are: Location, Room, Chief Complaint and Triage (Patient’s MOA must be entered) along with the ESI level.
14Allergies Allergies is accessed on the second tab of Triage Allergy information crosses to PCS, OM etc.Allergies must be entered to place orders in OMAllergy information is recalled on the medical record based on what was entered in the patients last visit.
17ED Visit Data ScreenThe ED Visit Data Screen is an additional screen where you can update the patients room and location.To access the screen go to Open Chart -> ED Visit Data
18Documenting in Meditech Ensure that you are logged onto the computer under your own name and have a pinAll entries are part of the patients legal Medical Record and time stampedOnly answered questions appear as part of the Medical RecordBe sure to lock down or sign out of your PC when leavingAll documentation must be completed prior to Discharge or Admit and before end of shift.Always remember to SAVE your documentation!
19Things that MUST be Documented in Meditech on every patient Complete Triage AssessmentAllergiesPatient HistoryCC AssessmentRN Disposition Documentation (part of Discharge Routine)
20Things that need to be documented in Meditech as applicable Additional Focus of Care itemsAdditional Vital Signs and Progress NotesIV site Intake and Output/ Add an IV or Add a VoidCritical ValueTreatmentsOther
21Chief ComplaintsBy choosing a Chief Complaint at Triage you are driving documentation onto your work list.
22NotesYou have the ability to add a Progress Note in the Vital Signs and Progress Note Assessment (typically this is what is being utilized for notes)You also have the ability to document anything in the comment section in each one of the CC driven assessments.
28Oops!With edit and undo options you have the ability to edit incorrect documentation done on a patient.You also have the ability to remove the entire assessmentIf you need to back date the time that can be done as well either when initially documenting or at a later time through edit
31Printing A Patient Report Click the ED Summary button from the TrackerPrint the ED Summary this contains the complete SBAR format information of the patients visit.
32Things that are still on paper CodesProcedural SedationState Mandated FormsCobraSection 12Consents
33EMR Review Highlight the Patient and Open the Chart Click on Clinical PanelChoose the EDHere you can review all EDdocumentation (this is utilized byED Physicians, medical records andinpatient Nurses)EMR
34Discharge Accessed through Open Chart The discharge date/time should be entered for when the patient is leaving the department this function is done by the CAN staffThe discharge intervention should also be filled in a the time of dischargeOnce both are complete and accurate the Discharge can be saved.