Presentation on theme: "Before we Begin Practice Logging in to ensure your password works appropriately Once you have logged in, select the status board Select Lists Select Find."— Presentation transcript:
1 Before we BeginPractice Logging in to ensure your password works appropriatelyOnce you have logged in, select the status boardSelect ListsSelect Find Patient by Inpatient LocationSelect Test IP LocationFind patient: EMR TESTLaunch the Open ChartClick MAREnter your PIN – Make sure you know your PINIf you need to reset your PIN – Please call the support center x 4031
3 Acronyms PCS: Patient Care System Care PlanningIntervention and Outcome DocumentationMedication DocumentationNotesMAR: Medication Administration RecordMedication Administration DocumentationBMV: Bedside Medication VerificationScanning Medication Barcodes to verify 5 RightsEMR: Electronic Medical RecordReview clinical documentationOM: Order ManagementEnter Orders
4 Agenda PCS: Patient Care Systems OM: Order Management OverviewStatus BoardWorklistCare PlanningDocumentation FunctionsOM: Order ManagementHow to Enter OrdersClinical Data ScreenEMR: Electronic Medical RecordReviewing patient information
5 New Admission and Care Plan Process Video Demonstration INew Admission and Care Plan ProcessNew Admission and Care Plan Process
6 Nursing Main Menu List of Routines and Reports PCS Status Board will provide most nursing care routinesAdditional routines will be covered in more detail in Session II
8 PCS Status Board Patient Assignment List/Home Page Status Board Function ButtonsPatient Assignment List/Home PageDisplays Pertinent Patient InformationRelevant to the particular patient locationie: Psych, MedSurg, Rehab, etcContinuously Refreshes with new information (every 5 minutes)Launching pad to various patient care routinesPatient Care Routines & Function Buttons
9 My List Manually Add Patients to your list Pts are Retained From One Log-on to the NextDischarged Patients Remain on your Status Board until manually removedEnables Care Provider to Complete Documentation even after the patient has left the facilityManually Remove Patient from your ListOnce you have Completed your Documentation and the patient has been discharged (or you are leaving for the day)The more patients on your List the longer the status board will take to load
10 Adding Patients to your List [Lists] Button provides options to search for and add patients to your ListFind AccountSearch for single patient by patient nameFind Patient by Inpatient LocationProvides a list of patients admitted to each locationProvides the ability to add multiple patients to your list at one timePreferred methodMy ListLaunches your patient assignment list
11 Video Demonstration II PCS Status BoardPCS Status Board
12 Exercise A: Find Patient by Location Click [Lists]Click [Find Patient by Inpatient Location]Select [Test MVH IP Location]Click [Assignments] - Right hand panelPlace a checkmark to the left of the following patient’s namesEMR, TESTPATIENTAEMR, TESTPATIENTBClick [Add to My List] -Footer ButtonClick [Lists] - Right hand panelSelect [My List]Confirm that both patients have been added to your assignment list
13 Exercise B: Find Patient by Account Click [Lists]Click [Find Account]Type Patient’s Name (Last Name, First Name)Use the first Patient on the card taped to your PC.Click to the select the patient accountSelect the Account Number with the Admin In Registration TypeThe status Board will AppearClick [Add to My List] – Footer ButtonSelect [My List]Confirm this new patient has been added to your List
15 Open Chart All Inclusive Nursing Care Routine Review Patient Data Complete Assessment, Outcome, and Medication DocumentationEnter OrdersEnter Allergies and Home Medications
16 Open Chart EMR Electronic Medical Record OM Order Entry Review Patient DataOM Order EntryEnter OrdersPCS Patient Care SystemMAR Medication Administration RecordDocument MedicationsCare PlanningAdd the Care PlanWorklistIntervention & Outcome DocumentationWrite NoteClinical DataEnter AllergiesEnter Home MedicationsEnter/Review Patient informationEMROMPCS
17 Open Chart: Patient Header Medical Record NumberAge, Sex DOBHeight/Weight/BSALocation, Room, BedCode StatusAllergiesAdmit StatusAccount Number
22 Adding the Plan of CareIn Meditech, the first step for a new admission is to add the Care PlanSelect a location specific Care PlanIncludes Problems, Outcomes, Interventions common to any patient admitted to the particular locationOnce the patient has been fully assessed the Care Plan will be individualized
23 OB Delivery Care PlanAdmission,Physical, and Daily AssessmentsPainLocation specific Care Plan includes documentation common to any patient admitted to the particular LocationCare Plan ComponentsAdmission, Daily, and Physical AssessmentsPain
24 After Delivery…The specific focus of care selection for delivery (Vaginal, C/S, Perinatal Loss) will add:Appropriate Recovery DocumentationAppropriate PP Shift DocumentationAppropriate Teaching RecordsDischarge Documentation
25 Newborn Care PlanAdmission,Physical, and Daily AssessmentsPainFeeding & EliminationDischargeLocation specific Care Plan includes documentation common to any patient admitted to the particular LocationCare Plan ComponentsAdmission, Daily, and Physical AssessmentsPainFeeding & EliminationDischarge
26 WorklistInterventions and Outcomes will display on the worklist as added with the Plan of CareClicking the Frequency header will sort the list by frequenciesThis will help to clarify which interventions are to be documented upon Admission
27 Video Demonstration III Open Chart/Worklist/Add Care PlanOpen Chart Worklist Add Care Plan
28 Exercise C: Open Chart/Worklist/Care Plan Use the first TEST Patient on your PC paperClick [Lists]Select [My List]From your Assignment list, click to the left of the patient’s name to Launch the Open ChartConfirm the Standard of Care list automatically defaults to the worklistClick [Plan of Care] – Right Hand PanelClick [Add] – Footer ButtonSelect Care Plan: OB DELIVERY PlanClick [Save] – Footer ButtonReview the Care Plan ComponentsClick [Worklist]Confirm the Interventions and Outcomes from the plan of care appear on your worklistClick the frequency header to sort the worklist by frequenciesThis will highlight which interventions should be documented on admission
29 Admission Documentation The next step in the care planning process is to complete all admission documentation and physical assessmentsAdmission Assessments display separately on the worklistProvides clarity as to which assessments have been documented vs. those that have notProvides the ability to document one assessment or multiple assessments at one timeSame assessments are documented on admission as throughout the patients stayProvides the ability to view documentation over timeProvides the ability to compare the current state to the state of the patient upon admission
31 Documentation Overview Documentation mode defaults to flowsheetProvides a view of prior documentationMode Button will toggle to Questionnaire modeSimilar to a paper assessment
32 Documentation - Flowsheet Current Date/Time DefaultsGray Background = View ModeWhite Column = Documentation ModeRecall is Enabled for PMH
33 Documentation - Questionnaire Clicking Mode will toggle to Questionnaire StyleYou may toggle between Questionnaire and Flowsheet mode at any time within documentation
34 Video Demonstration IV DocumentationDocumentation
35 Exercise D: Documenting PMH Use the first TEST Patient on your PC paperStart from the worklistPlace a checkmark in the now columnClick [Document]Confirm the time column displays the current date/time in the headerReview the documentationDisplaying from the last admissionClick [Mode] to toggle to Questionnaire ModeDocument PMH: Asthma, Diabetes- Insulin Dependant, Tuberculosis, Eczema, Epilepsy, Patient is not at risk for aspirationAny Body Systems with a Negative Response should be documented as None ReportedClick [Save]Confirm the last done column updates with the last time the intervention was documented
36 EMR Patient Care Panel Displays PCS Documentation Assessments InterventionsOutcomeCare Plan
37 Exercise E: Reviewing Documentation - EMR Use the first TEST Patient on your PCClick [Patient Care Panel]Confirm that the [Assessment] Tab DefaultsSelect to view the Past Medical History DocumentationPlace a Checkmark to the left of the Assessment NameClick [View History]Confirm that all documentation displaysClick [Back]Click [Plan of Care] Tab – HeaderClick the [+] Symbol (in the description header) to Expand the Components of the Care PlanReview the Care Plan Components
40 OB Individualized Focus of Care The Joint Commission Requires that each Care Plan be IndividualizedIndividualized Focus of Care InterventionTool to assist with care plan customizationDocumentation occursAfter delivery to choose the appropriate selectionAfter the admission and physical assessments have been completed, as appropriateWhen additional problems are indentified, PRNBased upon the selections, problems and associated interventions will be suggested
41 NB Individualized Focus of Care Documentation on the focus of care occurs as problems are identified, PRN
42 Individualized Focus of Care Upon saving the focus of care selections, a list of problems is presentedHere, Vaginal Delivery and Diabetes (GDM/IDM) was selected
43 Adding ProblemsPlace a checkmark to the left of every Problem presentedClick [Ok]
44 OB Individualized Care Plan The newly added problems will be viewable within Care Plan Routine
45 Documentation Frequencies Outcomes, Assessments and Interventions from the care plan display on the WorklistOutcomes: required to be documented daily and upon dischargeInterventions/Assessments: vary based upon protocol and physician ordersFrequency column indicates how often to documentLast done column indicates the last time the assessment was documentedFrequencies can be edited as needed based upon a particular Order or Protocol
46 Video Demonstration V Individualizing the Plan of Care
47 Exercise F: Individualized Focus of Care Use the first TEST Patient on your PCStart from the worklistFind the *Individualized Focus of Care –OB InterventionClick in the now columnClick [Document]Select: Vaginal Delivery, Diabetes (GDM/IDM)Click [Save]A List of Suggested Problems should displayPlace a checkmark next to all and Save.Click [Plan of Care] – Right Hand PanelConfirm four new problems have been added
48 Individualizing the Problem and Outcome The next step in the care plan process will be to further individualize the problem and outcomeProblemIndicate the specifics to which the problem relatesOutcomeIndicate specific goals that are being set to achieve the outcome
49 Individualizing the Problem Once the problems have been addedSelect the Problem tabClick to edit the item detail field to indicate the disease process for which the problem is related
50 Exercise G: Customizing the Problem Use the first TEST Patient on your PCFrom the Care Plan Routine – Click the [Problem] TabClick in the item detail column for the Problem: PainClick [Edit] to enter text for the ProblemIndicate that this problem is “Related to vaginal delivery, gr 3 with a peri-urethral laceration”Click [Save]Notice an “I” Displays in the Item detail columnClick the I to view the Item DetailConfirm the newly documented info displaysClick [Back] to return to the plan of care
51 Individualize the Outcome Next, click the outcome tab to list the goals that will be set to achieve the outcomeFor each outcome, click in the item detail to indicate the specific goals will be set to achieve the outcome
52 Outcome Customization The documented goals will be viewable/editable from the worklist
53 Exercise G: Customizing the Outcome Use the first TEST Patient on your PCClick the Outcome Tab to review the outcomesClick in the item detail column for the Outcome: Reports pain at tolerable levelClick [Edit] to enter text for the OutcomeIndicate for the outcome that “Patient will demonstrate utilization of effective comfort measures”Click [Save]Notice an “I” Displays in the Item detail columnClick the I to view the Item DetailConfirm the newly documented info displaysClick [Back] to return to the plan of careClick Worklist and view the item detail text to view the outcome goals
54 Care Plan Process: New Admission Add a Location Specific Plan of CareOB Delivery or Antepartum PlanNewborn Plan of Care or NB Outside AdmIf a GYN use M/S/ICU Plan of CareComplete All Admission DocumentationOB Arrival to Unit Admit/TransferOB Admission AssessmentPast Medical HistoryOB Adm Physical AssessmentHt/WtOB Vaccine AssessmentAge 18+ Opt Out Vaccine AssessmentBraden/Skin Risk AssessmentFall Risk/Safety/Precautions AssessmentCustomize the Care PlanAdding Problems/Outcomes/Assessment based upon patient’s delivery status and/or condition
56 Documentation Functions Temperature, Height and Weight QueriesEnable you to toggle between English and Metric Units within documentationInstance Type QueriesEnable multiple instances of documentation for various body locations or situationsIV Insertions, Orthostatic Vital Signs, etc
57 Documentation - Calculator Enables you to toggle between English and Metric UnitsRegardless of the units of documentation, the display will default to English
58 Documentation – Instance Type Enables multiple instances of documentation for various body locations, positions or situationsIV Insertions, Orthostatic Vital SignsClick the drop down arrow to invoke the group responseSelect the body location/situationClick Ok
59 Documentation – Instance Type Document the fields for the situation/instanceRepeat the instance type documentation for the new body locationIn this case, BP and Pulse will be documented for Lying, Sitting, and Standing Positions
60 Documentation – Back Time To back date/time your documentation, click the drop down arrow in the headerAdjust the date/time to reflect when the data was collected
61 Documentation – Expand/Collapse Clicking the [-] symbol will collapse the field within the section
62 Documentation – Collapse Notice the temperature section is now collapsedYou may now click the [+] symbol to expandSome sections will default as collapsed – Notice the Thermal Management Documentation defaults this way and can be expanded as neededDocumentation that is infrequently utilized will default as collapsed and must be manually expanded as neededThe Manual Expand/Collapse will stick for the current assessment only
63 Exercise F Part A: Documentation Functions - Back Documenting Use the first TEST Patient on your PCSelect the [worklist] routineSelect Vital SignsClick in the now column for the Vital SignsClick [Document]Back Document 1 Hour in the PastIn the Header, click the drop down to the right of the Date/Time FieldChange the time to 1 hour in the pastNext Step – Next Slide
64 Exercise G Part B Documentation Functions – Calculator & Instance Type Temperature: 98.6 OralPulse: 62Orthostatic Vital Signs (Instance Type)Click “New Orthostatic Vital Signs” to start a new instanceLying Left Arm 120/80 Pulse 62Click “New Orthostatic Vital Signs” to start a new instanceSitting 118/78 Pulse 63Standing 115/70 Pulse 65Click [Save]
65 Exercise H: Review Documentation in EMR Click [Refresh EMR]Select [Patient Care Panel] in the EMRPlace a checkmark to the left of the Vital Signs AssessmentClick View HistoryConfirm that the Vital Sign Assessment displays under the adjusted time (1 hour in the past)Click [Back]Click the [Vital Signs] Panel of the EMR and review the documentation
67 Recall ValuesRecall Values provides the ability to pull prior documentation to the current assessmentThis function is enabled for a select number of assessmentsTo invoke the recall values function, click the [Recall] Button
68 Recall ValuesRecalls the entire assessmentRecalls the sectionRecalls the individual queryAssessment displays in greenA column of diamonds appear to the rightSelect the diamonds to recall individual queries, entire sections, or the whole assessmentIt is critical that you review the recalled information to ensure accuracy before savingRecalling & saving = Signing your name to the documentation
69 Exercise I: Recall Values Use the first TEST Patient on your PCDocument Past Medical HistoryClick in the now column to select the interventionClick DocumentClick RecallNotice the screen turns green and diamonds appear in the right hand columnClick to recall one query: select to the right of the cardiovascular historyClick to recall the section: select to the right of the cardiovascular past medical historyClick to recall the entire assessment: select to the right of the Past Medical historyConfirm the entire assessment has recalledReview all documentation to ensure accuracyUpdate the GI Past Medical History QueryClick Save
71 Worklist – Additional Functions Item Detail: Protocol, Associated Data, Item Detail InfoCare Item: Intervention, Assessment, OutcomeFrequencyLast DoneStatusWorklist displays active and discharge statuses by defaultAll other statuses are suppressed from view
72 Adding a New Intervention Most Interventions are added to the worklist through the plan of careAdditional Interventions may be added as neededTo add new interventions use the [Add] button
73 Add Intervention Routine The Quickest Method of searching for an Intervention is by [Any Word]Searches the entire intervention nameClick [Any Word] and type the intervention name you wish to add
74 Add Intervention Routine Type the name of the intervention and click enterSelect the Intervention from the List and click save
75 Exercise L: Adding a New Intervention Patient’s primary language is Spanish and she prefers to discuss health related issues in this language. You will need to utilize the Telephonic/Video Interpretation device to communicate with your patient and her family.Add the telephonic/video interpretation device intervention.From the Intervention worklist, click [Add]Type “Interpret” and hit [Enter] – Notice the intervention does not appearClick [Any word] – Notice the Telephonic/Video Interpretation Assessment appearsClick the Intervention to selectClick [Save]Confirm the Telephonic/Video Interpretation Assessment has been added to the worklist
78 Item Detail Clicking the Icons will launch the item detail screen Within Item Detail there are multiple tabsDetail, History, Flowsheet, and Associated Data
79 Item Detail Tabs Detail History Flowsheet Associated data Info about InterventionIntervention text (Post it note)HistoryAudit trail of changes made to the interventionFlowsheetDocumentation View in Flowsheet modeAssociated dataView of Data Fields related to the particular intervention
80 Item Detail History Tab Audit Trail of Changes Made to the InterventionActivity: Document, Edit, UndoUser that documented, Care Provider Type, and Detail related to the changeFooter buttons: Edit/Undo documentationAllows you to edit or undo your own documentation onlyYou may not edit or undo another users documentation
81 Item Detail: Info Item detail may be utilized as a communication tool In the text field enter a note related to the interventionIn this case, the patient’s blood pressure must be taken on the left arm
82 Item Detail: Edit TextEnter the text that you wish to display with the interventionClick save
83 Item Detail TextThe item detail will be viewable by clicking the “I” from the worklist or within the assessment
84 Video Demonstration VII Item Detail/Editing & Undoing Documentation Item Detail Edit and Undo
85 Exercise I: Item Detail/Editing Use the first TEST Patient on your PCLocate the Pain InterventionClick the “P” to invoke the Pain ProtocolReview the ProtocolClick [Close] to return to the worklistFind the Vital Signs InterventionClick in the [Item Detail] ColumnSelect the [History] TabSelect the last instance of documentationClick [Edit]Document that the patient is on room air and O2 Sat is 98%Click [Save]Confirm a new Edit Line Item displaysClick in the detail column (assessment icon) for the edit line item to review the old and new results
86 Exercise J: Item Detail Text Use the first TEST Patient on your PCFor the vital signs intervention, indicate that the blood pressure must be taken on the left armClick in the item detail screen for the Vital Signs InterventionClick the [Detail] TabIn the text field, click Type: Patient’s blood pressure must be taken on the left armClick [Save]Click [Back] to return to the worklistClick the “I” in the item details screen to view the informationThis is comparable to a post it note or Edit Text in MT MagicPlease note: The last documented text will print with the medical record
87 Editing Worklist Frequencies To edit a frequency, click on the frequency fieldThis will invoke a drop down menuIn the free text field type a “period” and enter a free text frequency (ie: .Q4H)
88 Change StatusIf an intervention is added in error, you may change the status to remove or suppress the intervention from viewClick in the status/due column and select to delete or complete the intervention
89 Change ViewThe worklist displays active and discharge status items (only) by defaultTo bring inactive entries to view click Change View
90 Change ViewThis routine provides the ability to update the worklist displayIn this case, inactive interventions are selected to be added to the display.Click Ok
91 Change View – Worklist Display Note the Inactive Intervention now appearsThis intervention can be brought back to active status by selecting to edit the frequency
92 Exercise K: Frequency and Worklist Status Use the first TEST Patient on your PCFind the Vital Signs InterventionEdit the frequency of the intervention to .Q4HClick in the frequency fieldType “.Q4H”Hit EnterConfirm the frequency is updatedChange the status of the Telephonic Interpretation Assessment to CompleteClick in the Status/Due columnSelect CompleteConfirm the Intervention no longer displaysBring the Telephonic Interpretation Assessment back to active statusClick Change ViewSelect Complete from the Intervention status listClick OkFind the Telephonic Interpretation Assessment and click CompleteChange the status to Active
95 Agenda Introduction to the EMR Allergies, Code Status Order and Order Set EntryConsults and Uncollected SpecimensAcknowledgment and Incomplete OrdersPost-Filing Edits to OrdersEntering Requisitions
96 Intro to EMR Electronic Medical Record Integrated system so same information is viewable regardless of point of entry or desktopCentral access point for all results, patient demographic information, reports, clinical documentation, and clinical data.
97 Intro to EMRSelected tabs represent the EMR, viewable from all desktops with shared informationPatient header includes name, age, DOB, ht, wt, MRN, Acct number, Reg status, location/room/bed, and allergiesItems that have information “new to you” will be highlighted in red.
98 “i”: More InformationSmall “i” next to patient name provides additional information such as allergies, height, weight, admit date and time, BMI, and Code Status.
99 Select Visits PanelThis panel allows you to select the visits for which you wish to view patient data. Choose a time period and visit type, or manually check off the visits you wish to view. Current visit is the default.
100 Summary PanelThe summary panel holds clinical, demographic, and legal information regarding the patient. Allergies, home medications and problems (diagnoses) can be edited via the blue edit button. Allergies and home medications are usually edited on the Clinical Data screen which will be covered later.
101 Summary Panel (cont)The legal indicators page of the summary panel includes important patient information such as patient rights information, language, immunization, readmission data, blood type, precautions, fall risk, and Braden score. This information is also viewable for all visits by selecting the “all visits” tab.
102 Review VisitReview visit contains pertinent admission information including reason for visit and physicians associated to this patient visit.The “More detail” footer button provides additional demographic and administrative information.The patient abstract can be viewed and printed using the “Abstract” footer.
103 NoticesThe notices panel displays those notifications that have been sent to the physician desktop for acknowledgement. These include critical lab results, consultations, and certain nursing events such as patient falls.The Send Notice button will allow users to manually queue this notice to another physicians desktop that may need to be aware of the result/event.
104 New ResultsThe New Results panel shows new labs and reports that are new to you. They can be sorted to include data from the last 24 or 48 hours. Tests with multiple results will be listed in a separate date/time column.All critical results in Meditech are shown highlighted in red/pink and abnormal results will always show in yellow. Clicking on the result will show additional information including the reference range for the test.
105 Clinical PanelsClinical panels are constructed to provide a comprehensive view of the patient by pulling various types of patient data onto one panel. Additional clinical panels can be found by selecting the “Panels” footer button. Displayed is the M/S Handoff panel.Information is trended by date/time, but different time increments can be selected using the footer buttons.You can also choose to pull in data from previous visits by selecting the Visits footer button.
106 Vital SignsDocumented Vital Signs from the nursing assessment appear here. Additional documentations will be trended in an adjacent column by date/time. For patients with large amounts of documentation, the arrows at the top of the screen allow for scrolling through older documentation.
107 I&ODocumented intake and output will be listed here. Again data will be trended by date and time and can be adjusted to display increments of 1, 4, 8, 12, and 24 hours.
108 MedicationsThe default on the Medications tab, is the medication list which is a simple list of all medications during this patient’s visit, but can be expanded to include medications from all visits.Clicking the header of each column allows the list to be sorted accordingly. Additional filters can be applied using the footer buttons at the button.
109 Medications contThe second tab on the Medications panel provides a view only display of the MAR. All information on the MAR can be viewed, but no documentation can take place here. You must visit the true MAR for this.The detail footer button allows for viewing of additional medication information, such as the flowsheet, monograph, medication detail, protocol/taper schedules, and any associated data.
110 LaboratoryThe Laboratory Panel displays all lab data separated out by category. This defaults to the visits selected, but all visit data can be displayed by choosing that tab. Clicking the name of the test will launch you to a list of all results for that test. Clicking the result itself will launch you to a screen to view additional test data, such as the reference range.
111 Laboratory contLab reports can be printed by clicking on the date and time header of the lab panel. The user will be launched to a collection data screen, where he/she can select lab report and print the data.
112 MicrobiologyThe Microbiology panel displays all microbiology tests that have been received into the lab. The status and results will be displayed with the procedure. Clicking on the notepad will launch the user out to the final report.
113 Blood BankThe Blood Bank Panel allows for Blood related information to be tracked on the patients. The LAB/BBK department will update information in this panel along with the Blood Product Infusion Record/Reaction documentation done in nursing.
114 ReportsThe reports panel shows all reports that have been entered on the patient, including radiology report, cardiology reports, dictated physician reports, physician documentation reports, as well as Allscripts reports once they are live in the system. *Initially Allscripts reports will be housed in the patient paper chart. Clicking the notepad will launch you to the report for viewing and printing.
115 Patient CareThe Patient Care tab provides a view only overview of all assessments and interventions documented on the patient. The plan of care is also viewable from here. The information can be sorted out by date, name, recorded by, and provider type.
116 Patient Care contClicking onto the name of an assessment or intervention will launch you into a view only display of the documentation. No edits can be made from this panel.
117 NotesThe notes panel displays all notes entered on the patient by nursing, physicians, and other staff. Dictations and Physician Documentation reports (such as Progress Notes, H&P, Discharge Summary, etc) are not found here. They are on the reports panel. To view, either check off the box next to the desired note and click “View Selected” or clicking directly on the note.
118 OrdersOrders will be discussed in detail later in the training. For purposes of the EMR, however, the orders panel is accessible to all users on any desktop. All active orders will be displayed on the current orders table and the history panel contains these as well as cancelled, completed, and discontinued orders.
121 Exercise M: EMR Use: MTPatient,TEST Where are two places in the EMR that I can find documented allergies on a patient (Hint: Clinical data is NOT part of the EMR)?Where can I view the last medication administration in the EMR (Hint: your nursing MAR is not part of the EMR)How can I easily tell whether a lab is of abnormal or critical value?If I want to see a trend in a patients vital signs, how would I accomplish this?
122 EMR Hands-On Use MTPatient,Test What is the easiest and most succinct way to locate a patients standard of care and individualized plan of care?It is the end of your shift and you are preparing to hand off your patient, where would be the best place to find a comprehensive overview of that patient for that shift?
123 AllergiesIn addition to the summary panel, allergies can be entered on the Clinical Data screen. Allergies can be entered and edited by clicking the blue edit button.
124 Allergies contTo add a new allergy, click the “New” tab, and free text in your entry. A list of allergies should appear for you to select from. If your selection does not appear, the option to add the allergy as uncoded is available, but it is important to note this selection will NOT be included in interaction checking.
125 Allergies contClicking on the allergy that is appropriate will launch you to the edit screen where you will be required to enter the type allergy (or adverse reaction), status, and the reaction associated. Allergies that are new will be highlighted on the list in green for editing. The Audit button gives a beginning to end view of the life of an allergy including edits made and by whom.
127 Exercise N: Allergies Enter a Penicillin Allergy Reaction: AnaphylaxisSeverity: SevereEnter “Little Blue Pill” – Uncoded AllergyReaction: NauseaSeverity: MildSaveMake an edit to the little blue pill – Change to an Adverse ReactionObserve the audit trail.Observe the status in the EMR.
128 Code Status Code status is entered as an order Prior Advanced Directives DocumentedCode StatusCode Status Limits (if applicable)Advanced Directives Discussed and confirmed with
129 Code Status Order/Display Once the code status is enteredCode Status displays in Patient HeaderCode Status and Limits displays in Summary Panel of the EMRCode Status, Limits, Advanced Directives, and Health Care Proxy display in Clinical Panel – Code Status/Advanced Directives
130 EMR Summary Panel Display - Code Status and Limits Patient header displays Code StatusEMR Summary Panel displays Code Status and Limits
131 EMR Clinical Panel Display Code Status/Advanced Directive Clinical Panel displaysCode StatusCode Status LimitsAdvanced DirectivesHealth Care Proxy
132 Exercise: Code Status Use Test Patient A from your PC Enter a code status orderFull Code with LimitsLimits: No DialysisSave the OrderConfirm the Code Status Displays in the patient headerReview the EMR Summary Panel – Legal Indicator TabReview the Code Status Clinical Panel
133 Order ManagementPhysicians will Go LIVE with Computerized Physician Order Entry on July 1stMost Orders will be entered directly into MeditechIn the (rare) event that the MD is not able to enter the order into Meditech, orders may be entered for the MD by a Unit Secretary (Non Med Orders), or NurseThe next training segment will review the steps for Entering Orders, Order Sets and Medication Orders
134 Order Entry- Procedures Full orders functionality will be shown in the CBT coming up. To provide an overview, all non ordering providers will select an ordering provider and source upon selecting “New Orders”. This will launch you to your selection screen where you can order off of favorites, by category group, or by typing ahead in the name tab. With the type ahead, select the desired order. Multiple orders can be queued up by clearing the search field after selection and typing ahead again.
135 Orders continuedClicking next will launch into the Edit Order list where all new orders and any potential duplicate orders will display. Any orders that have fields requiring edits will have an asterisk. Clicking that order will display the edit screen and fields with asterisks must be completed.
136 Editing Order Frequency In the edit screen of an order, the frequency field can be free texted in. For series orders, the system recognizes DAILY and QXH. Simply enter the count in the count field and the stop time will automatically calculate. For DAILY orders the start time automatically defaults to the morning draw. Once all requirements are satisfied clicking next will take you to the Manage Orders screen where additional edits can be made if necessary.
137 Orders contOnce you have reviewed on Manage Orders and click next you will be taken to the Current Orders table where new orders will be displayed with a green “New” status until filed. Clicking submit files the orders. Physicians require pin entry before filing.
138 Order SetsOrder sets are available for use by nursing should it be appropriate. They are especially useful in the ED where the Med Approved Protocols are available for use. The sets group orders together to support evidence based medicine and can be ordered by category or by searching by name. Multiple sets can be selected at one time.
139 Order Sets contOnce the sets are selected, the manage orders list allows you to select the orders that are needed. Edits can be made by clicking the blue edit button on an individual order or by selecting edit all which will queue up orders for editing. The functionality here is identical to orders and they will be filed in the same way.
140 OrdersOrder Management for Non-Ordering Providers
141 Order SetsOrder Sets for Non-Ordering Providers
142 Exercise O: Orders Enter orders from different categories Imaging, Card, US, Lab, Mic, Bloodbank, Nursing, ConsultsMake edits both individually and using “edit all”. Make one of the orders a DAILY order by free texting in the frequency field of a routine order.Make note of the different screens on different types of orders.Enter the Admit to General Medicine Order setSelect any orders relevant to your patientFile all orders together.
143 Entering Medication Orders First Select Ordering Provider and Order Source and Click [Next]Select [New Meds]Type the name of the medication and select the name from the search ahead lookup
144 Entering Medication Orders Place a checkmark next to the appropriate scheduleClick Edit to enter required informationUpdate the Medication OrderClick Submit and Save (or continue to enter additional medication orders
145 Medication Ordering Process One the medication orders have been entered, pharmacy will be required to verify the orders before they will be available on the MAROnce Pharmacy has verified the orders, you will Acknowledge the Orders and document the administrationsMAR Documentation will be covered in session II
146 Exercise: Entering Medication Orders Enter the following Medication Orders into Meditech:Enoxaparin 30 mg SC DailyLisinopril 10 mg PO DailyFurosemide 20 mg PO DailyClick [Orders]Select the Ordering Provider and SourceClick [Ok]Click [New Meds]Use the type ahead lookupSelect the appropriate order stringClick [Next]Edit the order informationClick New MedEnter the last 2 medications and click submit at the endNavigate to the Status Board and Select the Orders queue to confirm that the 3 new medication orders have been entered
147 Consult OrdersThe edit screen of a consult order differs for ordering versus non-ordering providers. Physicians are not require to enter consulting provider, so their consults file as incomplete to be completed by the nurse or secretary. Once the consulting provider information is entered additional information regarding communication to the consulting provider should be entered. A notification is sent to the physicians desktop when this information is entered. Incomplete orders will display on the statusboard as such and on the current orders table.
148 Uncollected Specimens When a lab or micro specimen is ordered and set to be collected by the nurse, it will flow to his/her worklist for collection. To document that it has been collected, check in the now column and click document. If a source has not been entered, it must be entered at this time. Filing the documentation automatically updated the order to collected and it is filed in lab.
150 Exercise P: Uncollected Specimen Use the first TEST Patient on your PCPractice entering various consult orders and note the required fields.Place multiple lab and micro order set for the Nurse to collect. Note the status of the order on the current orders table. Collect specimen off of worklist.
151 Acknowledgement of Orders All orders and order edits must be acknowledged by nursing. The Ack column on the status board allows for this to be done efficiently. Stat orders will be flagged as Stat and highlighted in pink. Routine orders will display with “Ack” in the column. Click into the column to acknowledge.
152 Acknowledgement contEach order must be selected and reviewed individually to acknowledge. Once you have reviewed each order, click the Acknowledge button. To restore them to unacknowledged before filing hit Undo. Otherwise click save to file the acknowledgment. You will then be brought to the manage orders screen.
154 Exercise Q: Acknowledging Orders Use the first TEST Patient on your PCClick into the Ack queue on the status board for your patient.Check off each order individually.Review Order Detail.File.
155 Editing after FilingTo edit an existing order, click on the order in current orders, and make any edits on the edit order list page that you are brought to. Editing a connecting order (lab, pha, mic, rad, card) will place a stop request on the original order and file your edits as a new order.
156 Editing after Filing cont Orders can also be edited from the Edit Multiple Button located on the Current Orders table. Multiple orders can be checked off here and edited using the available footer buttons. Again for connecting orders, edits made to the connecting orders (outside of the specimen collection field) will place a stop request on the order and file the edits as a new order.
157 Exercise R: Editing Orders Use the first TEST Patient on your PCMake edits to both connecting (labs, mic, rad) and non-connecting (nursing, consults, diets) orders to observe the change in statuses. Make note of those orders that stop request when edited.
158 RequisitionsRequisitions are a means of communication for information that isnot patient specificRequisitions can serve as requests for supplies or communications toother departments
159 RequisitionsOn the edit screen simply enter in your message/communication. Once filed the order will print to the receiving party.
161 Exercise S: Requisitions Use the first TEST Patient on your PCEnter the Requisition desktop and observe the different requisitions for the Morton facilityPractice entering requisitions.
162 Suggested Orders – Nursing Documentation Some Nursing Documentation is set to trigger suggested orders/consultsie: OB Admission Assessment may triggerSocial Services Consult, Nutrition Consult, etcIn this case, answering yes to the nutrition consult query will trigger a suggested order for a nutrition consult
163 Suggested Order The suggested orders screen displays Select the order and select Order Now or Undecided Remind again (if not appropriate)To proceed to Order Management, Click Ok
164 Suggested Order – Order Management The ordering provide and source will be selectedManager Order fields will be documentedAnd, once the order is ready to be transmitted, click Submit
165 Exercise T: Suggested Orders Use the first TEST Patient on your PCDocument the OB Admission AssessmentTypically, you would document all fields. For this example, document only the information indicated below under the OB General Information section:Information Provided by: PatientPatient Smoking Status: Never SmokedNutritional Consult indicated-YESPatient has an Advanced Directive and it is on file from prior visitPatient has a Health Care Proxy and it is on file from prior visitClick SaveYou are brought to the suggested orders screen
166 Exercise: Suggested Orders cont’d From the suggested orders screen, select Nutrition Consult and click Order NowClick [Ok]From Order Management, select the ordering provider and the order sourceYou are launched into Order ManagementEnter the required fields (indicated by an *) and any additional informationNext, click SubmitThe order has been enteredNavigate back to your status board – Click My ListNext, Click the ACK prompt for your patientAnd, confirm the nutrition consult has been orderedAcknowledge the Nutrition Consult
168 OB Daily Documentation Vital SignsOB Shift Assessment (which includes):OB ADL RecordPostpartum AssessmentPhysical Systems AssessmentsFall Risk/Safety/Precautions AssessmentPain AssessmentPatient TeachingOutcome Documentation
169 NB Daily Documentation Vital SignsHt/WtNB Physical AssessmentNB Shift Care RecordNB Feeding RecordNB Breast Milk check for dispensing EBMNB Elimination RecordNB Pain AssessmentOutcome Documentation
170 Physical Assessments Within Normal Limits For admission, the OB Adm Physical Assessment will be usedFor assessments after delivery, physical assessments will be found in the OB Shift AssessmentDocument abnormal findingsIf the patient is within normal limits, you may use the within normal limits statement to indicate this finding
171 Clinical Update Panel Comments Within each of the physical assessments, there is a Clinical Update QueryThis is to document notable events related to the particular body systemThis query pulls to several EMR panels & provides a snapshot of notable eventsSupports communication between the care team members and can be viewed in the Clinical Update Panel
172 OB Clinical Review Panel Used for information snap shot and hand-offUseful for nurses as well as OB’sIncludes:VSPrenatal HxDelivery InfoPP AssessmentPIH dataLabsMedications
173 NB Clinical Review Panel Used for information snap shot and hand-offUseful for nurses as well as Pedi’sIncludes:VSDelivery InfoWgt/Length/I&OFeeding RecordLabsMedications
175 PP, NB and Breastfeeding Education Each of these interventions uses the “Instance function” for documenting the individual topicsThis will display all of the topics that have been “covered”, making education efforts more focusedThis information can be seen in the EMR panel:Education ReviewDocumentation Example:OB PP Education: Topics:
176 OB and NB Outcome Documentation All outcomes are documented dailyOB and NB outcomes have “criteria” which explain what is meant if the goal is “met”Additional comments are always welcomed to make the documentation more individual for the patient and further explain why an outcome may not be met or only progressing toward goal, along with any changes in the “plan”The education outcome states whether education was provided or not and there is a comment to describe anything pertinent about the efforts to education PRN
177 Exercise U: Physical Assessments – Within Normal Limits Use the first TEST Patient on your PCPlace a Checkmark next to the OB Adm Physical AssessmentDocument the Cardiovascular Assessment is within normal limitsDocument Crackles in the left upper lobe for the respiratory assessmentDocument the patient had wheezing that was treated by RT at 1200 in the Clinical Updates CommentDocument Genitourinary Assessment is within normal limitsSaveReview the documentation in the M/S- Hand Off Panel (as an example) and in the Clinical Update PanelNote: physical assessments do NOT go to the OB or NB Clinical Review panels
178 Exercise Vital Signs Teaching Intake and Output Assessment Document a set of vital signsTeachingDocument the OB/NB Infant Care EducationDocument that you taught the mom about Infant cues and communication and that she verbalized an understanding of the informationIntake and Output AssessmentDocument intake for the shift: 100 mlsUrine Output: 50 mls from indwelling catheterOutcome DocumentationPlace a checkmark next to outcomes of Maternal /Fetal risk and Stable PP recoveryMaternal/Fetal Risk->Document “Goal Met”Stable PP recovery->Document “Progressing Toward Goal” with comment “Increased bleeding in immediate postpartum, requiring additional medication”Change status of Maternal/Fetal Risk to Complete as it no longer needs to be documented
179 Notes Routine Write Note provides the ability to enter free text notes Most Documentation is included within the AssessmentsAdditional Information should be entered within the Assessment commentsNotes should rarely be utilizedReserved for unusual events that are not available within the assessmentsAlso utilized to generate Discharge Instructions and Page 2 ReportsBe careful not to double document within the notes routineAll Clinical Documentation is viewable from within the EMR
180 Notes Routine To begin documenting click write note Next, select the note category (i.e. Nurse)
181 Write Note You may choose to document a free text note Or, select Text to enter a canned text (pre populated note)
182 Canned TextUpon selecting canned text, a list of available notes will displayOnce the canned text is selected, the pre populated information will display within the write note screen. Canned text may be edited before saving.
183 Exercise V: Notes Routine Use the first TEST Patient on your PCSelect Write NoteSelect Note Category: NurseSelect the Text ButtonFrom the list of Canned Text, Select Patient Off UnitClick F4 to navigate through and enter each of the free text fieldsClick OkClick Refresh EMRNotice the Notes Button Turns RedClick to view the note within the EMR
184 Comprehensive Exercise Use the SECOND TEST Patient on your PCFind Patient by AccountAdd Patient to your ListAdd a new OB Delivery Plan of Care (pt is being admitted for a scheduled C/S)Enter Patient Allergies and Height and WeightDocumentOB Arrival to Unit/Admit or TransferOB Admission AssessmentPast Medical HistoryOB Adm Physical AssessmentSelect the C/S Delivery from the OB Focus of Care and add the suggested problemsAdd a new intervention: Blood Product Infusion Record/ReactionDocument Patient TeachingDocument all outcomesReview all documentation in the Patient Care Panel of the EMR
185 How to Discharge a Patient: Registration Management
186 How to Discharge a Patient The Discharge Process will be covered in session 2DocumentationReportsInstructionsNext, you will learn to discharge a patient from registration management
187 How to Discharge a Patient From the main menu – select Registration Management
188 Discharge Routine Perform a lookup to select the registration status Type Patient Information to identify the appropriate patientClick Ok
189 Discharge RoutineSelect the patient account from the Account Lookup Screen
190 Discharge RoutineDocument the date and time of discharge and discharge dispositionClick Next to Navigate to the next screen and document the appropriate informationSave
191 Exercise: Discharging a Patient Navigate to your main manuSelect Patient RegistrationSelect the Discharge TabType: INName: Use your test patient (from your PC)Discharge Date: TodayDischarge Time: NowDischarge Disposition: HOMClick [Next] and enter “N” at required fieldClick [Save]Repeat process for 2nd patient used during this class