Transcript Slide 1

PCS/BMV Implementation
RN PAT, SDC, PACU
Session I
Acronyms
• PCS: Patient Care System
– Documentation
• Interventions
Agenda
• PCS: Patient Care Systems
– Overview
– Status Board
– Worklist
– Documentation Functions
Nursing Main Menu
• List of Routines and Reports
• PCS Status Board will provide most nursing care
routines
Status Board
PCS Status Board
Patient
Assignment
List
Status Board
Function
Buttons
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Patient Assignment List/Home Page
Displays Pertinent Patient Information
– Relevant to the particular patient location
• ie: Psych, MedSurg, Rehab, etc
Continuously Refreshes with new information (every 5 minutes)
Launching pad to various patient care routines
Patient Care Routines &
Function Buttons
My List
• Manually Add Patients to your list
– Pts are Retained From One Log-on to the Next
• Discharged Patients Remain on your Status Board
until manually removed
– Enables Care Provider to Complete Documentation
even after the patient has left the facility
• Manually Remove Patient from your List
– Once 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
Adding Patients to your List
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[Lists] Button provides options to search for and add patients to your List
– Find Account
• Search for single patient by patient name
– Find Patient by Outpatient Location
• Provides a list of patients assigned to each location
• Provides the ability to add multiple patients to your list at one time
• Preferred method
– My List
• Launches your patient assignment list
Video Demonstration II
PCS Status Board
PCS Status Board
Exercise A: Find Patient by Location
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Click [Lists]
Click [Find Patient by Outpatient Location]
Select [SDC.DSMH (Day Surgery) Location]
Click [Assignments] - Right hand panel
Place a checkmark to the left of two patient names
Click [Add to My List] -Footer Button
Click [Lists] - Right hand panel
Select [My List]
Confirm that both patients have been added to
your assignment list
Exercise B: Find Patient by Account
1. Click [Lists]
2. Click [Find Account]
3. Type Patient’s Name (Last Name, First Name)
– Use the Patient Assigned to you by your Instructor
4. Click to the select the patient account
– Select the Account Number with the REG SDC Registration
Type
– The status Board will Appear
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Click [Add to My List] – Footer Button
Click [Lists]
Select [My List]
Confirm this new patient has been added to your List
Open Chart
Open Chart
• All Inclusive Nursing Care Routine
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Review Patient Data
Complete Assessment, Outcome, and Medication Documentation
Enter Orders
Enter Allergies and Home Medications
Open Chart
• EMR Electronic Medical Record
– Review Patient Data
• OM Order Entry
– Enter Orders
EMR
• PCS Patient Care System
– MAR Medication Administration
Record
• Document Medications
– Worklist
OM
• Intervention & Outcome Documentation
– Write Note
• Clinical Data
• Enter/Review Patient information
PCS
Worklist
Worklist
Open
Chart
Routines
Worklist
Worklist
Functions
• Open Chart defaults to the worklist tab
• Documentation Routine
– Interventions, Assessments, & Outcomes
Worklist: Standard of Care
• Upon registration a Standard of Care Automatically defaults
 Contains Standard Interventions most locations document
 Only document the Interventions which pertain to the Surgical Areas
Care Plan Process: New Admission
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Launch the Open Chart
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Use Patient Assigned to you by your instructor
Confirm the Standard of Care Displays
Add the Standard of Care: *PAT/Amb - Day Surgery Admit-Set
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Click Add
Select the Standard of Care Tab
Click *PAT/Amb – Day Surgery Admit-Set
Click Save
Confirm the following Interventions display
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Ambulatory/Day Surgery Adm Information
Columbia Suicide Risk Rating Scale
IV/Invasive*Line Assessment
PACU Holding Area-Inpt/ED Preop Note
PACU*Record
Past Medical History
Phase II/*Outpt Post Procedure Recovery
Post Surgical Consult Review
Pre-Adm Testing (PAT) Admission Info
Pre-Surgical Documentation Reviewed
Skin Assessment
Sort by Frequency
• Clicking the Frequency header will sort the list by
frequencies
Documentation Overview
Documentation Overview
• Documentation mode defaults to flow sheet
 Provides a view of prior documentation
• Mode Button will toggle to Questionnaire mode
 Similar to a paper assessment
Documentation – Flow sheet Mode
Current Date/Time
Defaults
Gray Background =
View Mode
White Column =
Documentation
Mode
Documentation - Questionnaire
• Clicking Mode will toggle to Questionnaire Style
• You may toggle between Questionnaire and Flow sheet mode at any time within
documentation
Video Demonstration IV
Documentation
Documentation
Exercise D: Documenting PMH
1. Start from the worklist
2. Place a checkmark in the now column
3. Click [Document]
– Confirm the time column displays the current date/time in the
header
– Review the documentation
• Displaying from the last admission
4. Click [Mode] to toggle to Questionnaire Mode
5. Document PMH: Asthma, Diabetes- Insulin Dependant,
Tuberculosis, Eczema, Epilepsy, Patient is not at risk for
aspiration
6. Any Body Systems with a Negative Response should be
documented
7. Click [Save]
8. Confirm the last done column updates with the last time the
intervention was documented
EMR Patient Care Panel
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Displays PCS Documentation
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Assessments
Interventions
Outcome
Care Plan
Exercise E: Reviewing Documentation EMR
• Click [Patient Care Panel]
• Confirm that the [Assessment] Tab Defaults
• Click the [Name] Tab – This simplifies the list of
Assessments
• Select to view the Past Medical History Documentation
• Place a Checkmark to the left of the Assessment Name
• Click [View History]
• Confirm that all documentation displays
• Click [Back]
• Click [Plan of Care] Tab – Header
• Click the [+] Symbol (in the description header) to Expand
the Components of the Care Plan
• Review the Care Plan Components
Documentation Functions
Documentation Functions
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Temperature Query
 Enables you to toggle between Fahrenheit and Centigrade
Height and Weight Queries
 Allows users to toggle between Metric and English
Instance Type Queries Documentation Functions
 Enable multiple instances of documentation for various body locations or situations
o IV Insertions, Orthostatic Vital Signs, etc
Documentation – Calculator
Temperature
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Temperature Query
– Enables you to toggle between Fahrenheit and Centigrade
– Will always default to Fahrenheit
Documentation – Calculator for Height and
Weight
• Enables you to toggle between English and Metric Units
• Regardless of the units of documentation, the display will default to Metric
Documentation – Instance Type
• Document the fields for the situation/instance
• Repeat the instance type documentation for the new body location
• In this case, BP and Pulse will be documented for Lying, Sitting, and
Standing Positions
Documentation – Back Time
To back date/time your documentation, click the drop down
arrow in the header
• Adjust the date/time to reflect when the data was collected
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Documentation – Expand/Collapse
• Clicking the [-] symbol will collapse the field
within the section
Documentation – Collapse
• Notice the temperature section is now collapsed
• You may now click the [+] symbol to expand
• Some sections will default as collapsed – Notice the Thermal Management
Documentation defaults this way and can be expanded as needed
• Documentation that is infrequently utilized will default as collapsed and must be
manually expanded as needed
• The Manual Expand/Collapse will stick for the current assessment only
Exercise F Part A: Documentation Functions
- Back Documenting
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Select the [worklist] routine
Select Vital Signs
Click in the now column for the Vital Signs
Click [Document]
Back Document 1 Hour in the Past
– In the Header, click the drop down to the right of the
Date/Time Field
– Change the time to 1 hour in the past
• Next Step – Next Slide
Exercise G Part B Documentation Functions
– Calculator & Instance Type
• Document
– Temperature: 98.6 Oral
– Pulse: 62
– Orthostatic Vital Signs (Instance Type)
• Click “New Orthostatic Vital Signs” to start a new instance
– Lying Left Arm 120/80 Pulse 62
• Click “New Orthostatic Vital Signs” to start a new instance
– Sitting 118/78 Pulse 63
• Click “New Orthostatic Vital Signs” to start a new instance
– Standing 115/70 Pulse 65
• Click [Save]
Exercise H: Review Documentation in EMR
• Select [Patient Care Panel] in the EMR
• Place a checkmark to the left of the Vital Signs
Assessment
• Click View History
• Confirm 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
Recall Values
Recall Values
• Recall Values provides the ability to pull prior documentation to
the current assessment
• To invoke the recall values function, click the [Recall] Button
Recall Values
Recalls the entire
assessment
Recalls the section
Recalls the
individual query
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Assessment displays in green
A column of diamonds appear to the right
Select the diamonds to recall individual queries, entire sections, or the whole assessment
It is critical that you review the recalled information to ensure accuracy before saving
• Recalling & saving = Signing your name to the documentation
Exercise I: Recall Values
• Document Past Medical History
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Click in the now column to select the intervention
Click Document
Click Recall
Notice the screen turns green and diamonds appear in the right
hand column
– Click to recall one query: select to the right of the cardiovascular
history
– Click to recall the section: select to the right of the cardiovascular
past medical history
– Click to recall the entire assessment: select to the right of the
Past Medical history
• Confirm the entire assessment has recalled
– Review all documentation to ensure accuracy
– Update the GI Past Medical History Query
– Click Save
Worklist Management
Worklist – Additional Functions
Item Detail: Protocol, Associated Data, Item Detail Info
Care Item: Intervention, Assessment, Outcome
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Frequency
Worklist displays active and discharge statuses by default
All other statuses are suppressed from view
Last Done
Status
Item Detail
Item Detail Column
• Item Detail Column
– P: Protocol
– A: Associated Data
– I: Item Detail
Item Detail
• Clicking the Icons will launch the item detail screen
• Within Item Detail there are multiple tabs
– Detail, History, Flow sheet, and Associated Data
Item Detail Tabs
• Detail
– Info about Intervention
– Intervention text (Post it note)
• History
– Audit trail of changes made to the intervention
• Flow sheet
– Documentation View in Flow sheet mode
• Associated data
– View of Data Fields related to the particular intervention
Item Detail History Tab
• Audit Trail of Changes Made to the Intervention
– Activity: Document, Edit, Undo
– User that documented, Care Provider Type, and Detail related to the change
• Footer buttons: Edit/Undo documentation
• Allows you to edit or undo your own documentation only
– You may not edit or undo another users documentation
Item Detail: Info
• Item detail may be utilized as a communication tool
• In the text field enter a note related to the intervention
• In this case, the patient’s blood pressure must be taken on the left arm
Item Detail: Edit Text
• Enter the text that you wish to display with the intervention
• Click save
Item Detail Text
The item detail will be
viewable by clicking
the “I” from the
worklist or within the
assessment
Video Demonstration VII
Item Detail/Editing & Undoing Documentation
Item Detail Edit and Undo
Exercise I: Item Detail/Editing
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Locate the Pain Intervention
Click the “P” to invoke the Pain Protocol
Review the Protocol
Click [Back] to return to the worklist
Find the Vital Signs Intervention
Click in the [Item Detail] Column
Select the [History] Tab
Select the last instance of documentation
Click [Edit]
Document that the patient is on room air and O2 Sat is 98%
Click [Save]
Confirm a new Edit Line Item displays
Click in the detail column for the edit line item to review the
old and new results
Exercise J: Item Detail Text
• For the vital signs intervention, indicate that the blood
pressure must be taken on the left arm
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Click in the item detail screen for the Vital Signs Intervention
Click the [Detail] Tab
In the text field, click [edit]
Type: Patient’s blood pressure must be taken on the left arm
Click [Save]
Click [Back] to return to the worklist
Click the “I” in the item details screen to view the
information
– Click [Back] to return to the worklist
– Please note: The last documented text will print with the
medical record
Editing Worklist Frequencies
• To edit a frequency, click on the frequency field
• This will invoke a drop down menu
• In the free text field type a “period” and enter a free text
frequency (ie: .Q4H)
Change Status
• If an intervention is added in error, you may change the
status to remove or suppress the intervention from view
• Click in the status/due column and select to delete or
complete the intervention
Change View
• The worklist displays active and discharge status items (only) by
default
• To bring inactive entries to view click Change View
Change View
• This routine provides the ability to update the worklist display
• In this case, inactive interventions are selected to be added to the display.
• Click Ok
Change View – Worklist Display
• Note the Inactive Intervention now appears
• This intervention can be brought back to active status by selecting
to edit the frequency
Adding a New Intervention
• Most Interventions are added to the worklist through the plan of care
• Additional Interventions may be added as needed
• To add new interventions use the [Add] button
Add Intervention Routine
• The Quickest Method of searching for an Intervention is by [Any Word]
– Searches the entire intervention name
• Click [Any Word] and type the intervention name you wish to add
Add Intervention Routine
• Type the name of the intervention and click enter
• Select the Intervention from the List and click save
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 appear
– Click [Any word] – Notice the Telephonic/Video Interpretation
Assessment appears
– Click the Intervention to select
– Click [Save]
– Confirm the Telephonic/Video Interpretation Assessment has
been added to the worklist
Write Note
• You may choose to document a free text note
• Or, select Text to enter a canned text (pre populated
note)
Canned Text
• Upon selecting canned text, a list of available notes display
• Once the canned text is selected, the pre populated
information will display within the write note screen. Canned
text may be edited before saving.
Exercise V: Notes Routine
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Select Write Note
Select Note Category: Nurse
Select the Text Button
From the list of Canned Text, Downtime Note
Click F4 to navigate through and enter each of the free
text fields
Click Ok
Click Refresh EMR
Notice the Notes Button Turns Red
Click to view the note within the EMR
Patient Care Reports
• Group of Meditech standard reports
• Available directly from PCS Status Board
• You may print Patient Care Reports for an
individual patient or a entire patient location
• Examples:
– Nursing Kardex
– Care Summary Report
– Active Orders Report
Patient Care Reports
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Click Patient Reports
Place a checkmark next to the patient’s name that you wish to print the report
Print for a location
– Navigate to find patient by outpatient location
– Clicking in the checkmark header to select all patients
Reports Routine
• From the Patient Report Format Prompt, perform
a look up to invoke the list of available reports
Patient Reports List
• You will be provided with a list of reports to choose from
• Select the report you wish to print
Patient Reports
• Click ok to print the report
Exercise: Patient Reports
• From the status board click the patient notes routine,
click the reports button
• Place a checkmark to the left of your patient’s name
• Click Reports
• Select the Drop down arrow
• Locate and Select the Vital Signs-Last 3 Days
• Click Ok
• And, select preview from the print/preview screen
PAT Workflow Process
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PCS Status Board
– Lists
– Find Patient by Outpatient Location:
• Day Surgery
Reg SDC account
Open Chart
– Go to the Summary panel
• Enter Allergies
• Enter Home Medication list
– Enter Last Taken Information
– Click on Worklist
– Click on Add in the footer
– Click on Standards of Care at the top of the screen
– Choose PAT/Amb Day Surgery set
• Save
– On the Worklist check off the following assessments:
• Height and Weight Assessment
• Past Medical History
• Patient Rights for Care Decisions
• Pre-Adm Testing (PAT) Admission Info
• Vital Signs
SDC Workflow Process
• Click on Worklist and document the following
assessments:
• Ambulatory/Day Surgery Adm Information assessment
• Pre-Surgical Documentation Reviewed
• IV/Invasive Line assessment to document the IV
insertion
• I&O Intake and Output assessment
• Vital Signs
PACU Workflow Process
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From PCS Status Board:
PCS Status Board
– Lists
– Find Patient by Outpatient Location:
• Day Surgery
SDC account or Inpatient account if patient was already an inpatient before going
to surgery
Open patient chart
– Click on Worklist and document on:
• PACU Holding Area-Inpt/ED Preop Note: for holding patients pre-op
• PACU Record
• IV /Invasive Line assessment
• I&O Intake and Output assessment
• Vital Signs
• Any other assessment needed for patient
If a patient comes to the PACU “holding area” from the ED or from the inpatient
units:
– Document the following assessment:
• PACU Holding Area-Inpt/ED Preop Note: for holding patients pre-op
For Outpatients going home from
either PACU or SDC
• Document the following assessment:
– Phase II/Outpt Post Procedure Recovery
assessment