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:
1Before 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.MOHFind patient: REHAB,TRAINLaunch the Open ChartSelect to suspend your sessionEnter your PIN – To re launch the sessionIf you need to reset your PIN – Please call the support center 4031
3Acronyms PCS: Patient Care System EMR: Electronic Medical Record Intervention and Outcome DocumentationNotesEMR: Electronic Medical RecordReview clinical documentationOM: Order ManagementEnter Orders
4Agenda PCS: Patient Care Systems EMR: Electronic Medical Record OverviewStatus BoardWorklistCare PlanningDocumentation FunctionsEMR: Electronic Medical RecordReviewing patient information
5Rehab Main Menu List of Routines and Reports PCS Status Board will provide most nursing care routines
6Rehab Main Menu A Physician Care Manager PCS Status Board EDM Tracker View Patient Information - EMRPCS Status BoardPatient Care Desktop (Contains several patient care applications)Inpatient or ED Worklist Documentation – Assessments/Interventions/OutcomesEDM TrackerED Patient Documentation - Assessments/InterventionsAdmissions - ReportsBed RosterDischarge Register
7Rehab Main Menu Reconciliation Menu Imaging and Therapeutic Services Therapists Desktop – Charge EntryReconciliation ReportsBilling ReportsImaging and Therapeutic ServicesManagement Routines and ReportsPrint Operating ListReport Routine: OR, PAT, Day Surgery SchedulesProvider Look-UpRoutine to Look Up Physician Contact Information
10PCS Status Board Patient Assignment List Status Board Function Buttons Patient 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
11My 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
12Adding 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 timeMy ListLaunches your patient assignment list
13Video Demonstration II PCS Status BoardPCS Status Board
14Exercise A: Find Patient by Account Click [Lists]Click [Find Account]Type Patient’s Name (Last Name, First Name)Use assigned REHAB,TRAIN patientClick 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
15Exercise B: Find Patient by Location Click [Lists]Click [Find Patient by Inpatient Location]Select [TEST.MOH Location]Click [Assignments] - Right hand panelPlace a checkmark to the left of a couple of patient namesClick [Add to My List] -Footer ButtonClick [Lists] - Right hand panelSelect [My List]Confirm that both patients have been added to your assignment list
17Open Chart All Inclusive Patient Care Routine Review Patient Data Complete Assessment DocumentationEnter Orders
18Open Chart EMR Electronic Medical Record OM Order Management Review Patient DataOM Order ManagementReview OrdersPCS Patient Care SystemWorklistIntervention/Assessment DocumentationWrite NoteClinical DataView AllergiesView Home MedicationsEnter/Review Patient informationEMROMPCS
19Open Chart: Patient Header Medical Record NumberLocation, Room, BedAge, Sex DOBHeight/Weight/BSAAllergiesAdmit StatusAccount Number
21Worklist Worklist Open Chart Routines Worklist Functions Open Chart defaults to the worklist tabDocumentation RoutineInterventions, Assessments, & OutcomesWorklist is shared by all Care ProvidersCare Items display based upon Care Provider TypePT Assessments display for Physical TherapistOT Assessment Display for Occupational TherapistsSLP Assessments Displays for Speech Language Pathologists
22Worklist: Standard of Care Upon registration a Standard of Care Automatically defaultsVital Signs will display for Rehab automaticallyFor the first encounter, you will add an intervention set before you begin documentingTo Add an Intervention or Intervention set, click the Add Button
23Rehab Intervention Sets Group of Interventions/AssessmentsAdded based upon services providedEach set will provide the basic interventions needed for all patientsAdditional interventions/assessments can be added as needed
24Rehab Intervention Sets: Physical Therapy PT Inpatient SetPT Inpatient EvaluationPT Inpatient Visit NoteGRP PT/OT Therapeutic ExercisesGRP Balance AssessmentGRP ROM AssessmentsGRP Gross Muscle StrengthPT Inpatient Orthopedic SetSame as above Plus CPM
25Rehab Intervention Sets: Occupational Therapy OT Inpatient SetOT Inpatient EvaluationOT Inpatient Visit NoteGRP PT/OT Therapeutic ExercisesGRP Balance AssessmentsGRP ROM Assessments
27Adding a New Intervention Set Intervention Sets or Individual Interventions may be added to the worklistAdditional Interventions may be added as neededTo add new intervention or set use the [Add] button
28Add Intervention Set 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
29Add Intervention Set Routine Type the name of the intervention set and click enterSelect the Intervention from the List and click save
30Exercise: Adding a New Intervention Set From the Status Board Launch the patient’s open chart by placing a checkmark to the left of the patient’s nameFrom the Worklist, click [add]Select Intervention SetsEnter PT, OT, or SLP (Based on your provider type)Select one of the followingPT Inpatient SetOT Inpatient SetSLP Inpatient SetClick OkConfirm that the Interventions display as expected
31Exercise: Adding a New Intervention Use the same patientFrom the Worklist, click [add]Select InterventionsSelect one of the followingSensation AssessmentStair Climbing assessmentSLP Voice EvalSelect the assessmentClick SaveConfirm that the Interventions display as expected
35Documentation Overview Documentation mode defaults to flowsheetProvides a view of prior documentationMode Button will toggle to Questionnaire modeSimilar to a paper assessment
36Documentation - Flowsheet Current Date/Time DefaultsWhite Column = Documentation ModeGray Background = View ModeRecall is Enabled for PMH
37Documentation - Questionnaire Clicking Mode will toggle to Questionnaire StyleYou may toggle between Questionnaire and Flowsheet mode at any time within documentation
38Video Demonstration IV DocumentationDocumentation
39Exercise D: Documenting Inpatient Eval Start from the worklistPlace a checkmark in the now column for the Inpatient EvaluationClick [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 the first Patient Profile Section and click saveClick [Save]Confirm the last done column updates with the last time the intervention was documented
40EMR Patient Care Panel Displays PCS Documentation Assessments InterventionsOutcomeCare Plan
41Exercise E: Reviewing Documentation - EMR Click [Patient Care Panel]Confirm that the [Assessment] Tab DefaultsSelect to view the Inpatient Evaluation DocumentationPlace a Checkmark to the left of the Assessment NameClick [View History]Confirm that 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
43Documentation Frequencies Assessments and Interventions for the patient display on the worklistFrequencies 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
45Documentation – Instance Type Enables multiple instances of documentation for various body locations, positions or situationsPT Treatment GoalsClick the New PT Short Term Goal textEnter free text
46Documentation – Instance Type Document the fields for the situation/instanceRepeat the instance type documentation for the new Short Term Goal
47Documentation – 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
48Documentation – Expand/Collapse Clicking the [-] symbol will collapse the field within the section
49Documentation – 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
50Exercise F Part A: Documentation Functions - Back Documenting Select the [worklist] routineSelect Inpatient Visit NoteClick in the now column for the Inpatient Visit NoteClick [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 pastDocumentSave
51Exercise H: Review Documentation in EMR Select [Patient Care Panel] in the EMRPlace a checkmark to the left of the Inpatient Visit NoteClick View HistoryConfirm that the Inpatient Visit Notes displays under the adjusted time (1 hour in the past)Click [Back]
53Recall 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
54Recall 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
55Exercise I: Recall Values Use your TEST PatientDocument Inpatient Visit NoteClick in the now column to select the Inpatient Eval 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 pertinent medical historyClick to recall the entire assessment: select to the right of the Inpatient EvalConfirm the entire assessment has recalledReview all documentation to ensure accuracyClick Save
57Rehab Problems/Goal/Plan Short Term Goals, Long Term Goals, and Treatment Plans are established in the Inpatient Evaluation
58Exercise: Documenting Patient Goals and Rehab Treatment Plan Document the inpatient evaluationPlace a checkmark in the now columnClick DocumentClick Mode to toggle to questionnaire modeScroll to the bottom of the assessment and find the PT Treatment GoalsIndicate two short term goalsClick new short term goal to start an instance and free text the first goalDocument the assessment
59Exercise: Documenting Patient Goals and Rehab Treatment Plan Click new short term goal to start a second instance and free text the second goalDocument the assessmentCreate a new instance for a long term goalDocument the patients treatment plan
60Review the Goals in the Rehab Summary Panel Click Clinical PanelsSelect Rehab Summary PanelConfirm that the Rehab Long Term Goals, Short Term Goals, and Recommendations display
61To Document ED patients PCS Status BoardListsAny Outpatient LocationED.MHFind Patient (In TEST: May need to use previous date)WorklistAddFind and Select ED Intervention
62ED Interventions ED PT Evaluation ED OT Evaluation ED SLP Bedside Swallow EvalED SLP Speech Language Eval
63Open Practice Session Practice Documenting – Assessment Review PT Inpatient SetPT Inpatient EvaluationPT Inpatient Visit NoteGRP PT/OT Therapeutic ExercisesGRP Balance AssessmentGRP ROM AssessmentsGRP Gross Muscle StrengthPT Inpatient Orthopedic SetSame as above Plus CPMOT Inpatient SetOT Inpatient EvaluationOT Inpatient Visit NoteGRP Balance Assessments
65Agenda Introduction to the EMR Allergies, Code Status Non-Med Order and Order Set EntryConsults and Uncollected SpecimensAcknowledgment and Incomplete OrdersPost-Filing Edits to OrdersEntering Requisitions
66Intro 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.
67Intro 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.
68“i”: More InformationSmall “i” next to patient name provides additional information such as allergies, height, weight, admit date and time, BMI, and Code Status.
69Select 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.
70Summary 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.
71Summary 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.
72Review 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.
73NoticesThe 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.
74New 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.
75Clinical 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.
76Vital 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.
77I&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.
78MedicationsThe 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.
79Medications 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.
80LaboratoryThe 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.
81Laboratory 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.
82MicrobiologyThe 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.
83Blood 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.
84ReportsThe 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.
85Patient 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.
86Patient 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.
87NotesThe 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.
88OrdersOrders 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.
90Exercise 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?
91EMR 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?On the day of go live, where should you go to find all scripts reports?