Transcript CPRS Training - Clark College

CPRS Training
June 2005
Patient Select Screen
Patient name, SSN, Last 4
Setup Default lists
Process Notifications
Patient Select Screen
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You can use the full SSN, Patient’s first initial of last name and last 4, full last name etc.
To look for Team lists, Select Teams from the Patient Select box and type the name of the team.
To process Notifications, Highlight the notification that you want processed and hit the Process
button. If you want to process all notifications, hit the Process All button. These notifications
are usually unsigned notes, orders, etc.
Team Lists
After selecting Team, type the
name of the team. To save the
list as your default, Press Save
Patient List Settings. This can
be done with any of the Patient
List types.
CPRS Cover Page
Menu Bar
Cover Page Areas
Tabs
CPRS Coversheet Overview
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Menu options
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Left click patient’s name to bring up Demographic information.
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There are Menu Options available for each Tab.
Left clicking File will let you pick a new patient or refresh patient information
Tools and Vista Apps have a number of links/programs that all areas may use.
To find Next of Kin, Last admission, surgery dates, etc.
Left click Provider box to select the Visit and Provider.
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Needed when entering orders or consults. This will be the provider that receives notification to sign an
order or get results from a test.
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Double left clicking any of the items on the cover sheet area will bring up more detailed
information for that item.
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Left clicking a tab will take you to that Page.
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Remote data will be highlighted if there is information available at other VA’s
Medications Tab
Medications Sections
Medications Section Continued
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First section will be Patient’s current location Medications
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If inpatient, there will also be listed Outpatient meds as well as non VA meds.
You can increase the viewable area of a section by left clicking and dragging a section.
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To Do This: Hover the mouse pointer over the edge of the area until it changes to a sideways T with up
and down arrows. Left click and hold the mouse down while increasing or decreasing the size of the area.
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Double click a medication order for more detailed information about the order.
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You can also increase the size of the columns.
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To Do This: Hover mouse pointer over the line that divides two columns. It will change to two arrows
with a horizontal line. Left click and hold the mouse down while changing the size of the column.
Orders TabTypes of orders that are viewed
Write orders using these
Orders written for this patient
To change what orders you see, Left Click View and then Custom Order View
Once you’ve customized your view, you can left click on “Save as Default”
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Highlight the Status and
Service/Section
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If you want to only display orders for a
specific time range, Select Only List
Orders Placed…
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To create a more specific list, Left click
the + in front of the name and then the
detail you want
Orders are Separated by Service
Order Start/Stop time and
Status
Who verified the order
Nrs=Nurse
Clk=Ward Clerk
Chart=Chart Review
Life of an Order
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Once an order is written, depending on the order type, it will have a Status (sts) of
unreleased.
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Releasing an order in CPRS is the same as signing an order on paper. For nurses taking
verbal orders, it’s the same as writing an order and signing it as a verbal order.
Once the MD signs the order or the RN releases the order, the status will change.
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Medication orders will have a status of Pending…until pharmacy verifies the order. After
verification, the orders will be Active. They may also be Expired, DC’d etc.
Medication orders that are not verified by Pharmacy will not have a stop date.
Text (Nursing) and some other types of orders once signed (released) automatically are
Active.
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To take action on an order. Highlight
the order and Left click Action
Nurse would also Complete an order
or verify an order from this option.
Release without MD signature allows
you to take a Verbal/Telephone order.
It is recommended that you use this
method when taking a verbal order.
Signature on Chart says that you are
putting in an order that is written on
paper some place.
Action also lets you Change an order
or Discontinue/ Cancel an order
**Note** If you verify an order before
it has been verified by pharmacy, you
may need to reverify that order.
If you want to take action on multiple
orders, hold the CTRL key down while
left clicking the orders
Verifying an Order
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Verifying an order means that it is Noted. You’ve seen the order and have
made sure that the order is handled as it should be (when applicable).
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If it’s a medication order, that its appropriate for the patient and that when the
time comes to give it, there are no reservations as you see it. For ECU, this may
also mean that you have ensured that the medication label or hand written entry is
on the MAR and ready to be administered.
Verification can also be done by ward clerks designating that they’ve seen the
order and if necessary, taken action on the order (printing lab requisition
slips/labels)
Verify an Order continued
Verification columns will be blank if the order is
not verified.
Verify an Order continued
To verify an order, left click to highlight then order
Then select Action from the menu bar
and then Verify
Verify an Order continued
Nurse
Ward Clerk
Once the order has been verified, the verifier’s
initials will appear on either the nurse
column or Clerk column
Notes
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The Notes Tab allow users to put in progress notes or other data that needs
to be seen by other users.
Notes are assigned titles and are usually attached too tools that help format
the note, called Templates
To write a New Note:
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Click on Notes Tab
Left Click “New Note”
Select a Note Title (if there is a template attached, it will launch, otherwise you
have a blank writing pad”
If you are using a template, once you are done, hit finish.
Sign the note using Action, “Sign Note Now” or Save the note to edit later with
“Save without signature”
Notes Tab
Note Titles
Body of the Note
Creating a New Note
Setting Up Note Titles
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From the menu bar, Left click Tools
and then Personal Preferences
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Left Click Notes tab
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Left Click Document Titles
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Leave Document Class set to Progress Note
In the Document Titles box, Start typing the name of the note you wish to add to your
default list.
Left click the title and then select Add.
The title will be displayed in “Your list of titles”. To remove it, highlight it and left
click remove
Once the custom titles are setup and New
Note is selected, the titles will appear
in this list.
New Notes
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Remember, when completing a note, all fields that have an * in front of them must be
filled in.
When the note is completed, select finish. This places your note in the chart,
Unsigned.
At this point you can either “Sign Note Now” or “Save Without Signature”
If you Sign the note, you will not be able to edit it…only add addendums to the note.
If you Save without signature, it saves the note so you can edit/add to it.
Save Without Signature
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If you’re using “Save Without Signature” to continue using a template in the future,
you must remember where you stopped on the template. It’s a good idea to stop end
of a section so you can start at the beginning of the next selection.
You must use the “Edit Progress Note” from the Action option in the menu bar. You
must also have the note you wish to edit highlighted
You’ll notice that your cursor will be placed at the bottom of the document that you
are editing. This is so that if you reuse a template, it will insert the new data at the
bottom of the note. You could move your cursor around and free type any text into
the note if you wanted too.
When editing a progress note DO NOT use the New Note option. If you find that
you have a blank page, its because you used New Note instead of Edit Progress Note.
If you signed the note, you will not be able to edit a note.
If you signed a note, you will not be able to delete a note.
Save Without Signature Continued
After Finishing a note, hit Action
And then Save Without
Signature
Save Without Signature Continued
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When you’re ready to edit the progress note
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Highlight the Unsigned note
Select Action from the Menu bar
Select Edit Progress Note from the list of options.
Select Templates and then left click on the + in front of Shared Templates
Scroll down to the name of the template that you are using
Sometimes templates are located by department or division.
Left click on the + to get to the section/note that you are using
Double click the template
Scroll down to the area that you left off in. Sometimes you have to open up areas that will
have *’s for required fields…such as the time of entry.
You can ignore the previous sections if you’ve filled them out already. The template is just a
tool to help you touch all the areas that need to be addressed.
Once you are done, select finish. You can “Save Without Signature” as many times as you
need too. Sign the note once it is complete.
Save Without Signature Continued
Highlight the unsigned Note
Left Click Templates
Save Without Signature Continued
Left Click the + in front of
Shared templates
Save Without Signature Continued
Scroll down to your area and
Expand the group by hitting
the +
Save Without Signature Continued
You’ll notice that the icon will
change from just a folder to a file
Folder combo
Lab Tab
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The Lab Tab gives you access to lab results. It allows you to display the data
in a variety of ways and is customizable to each user.
Lab Tab Continued
Various ways to view results
Results
Reports Tab
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The Reports Tab displays certain data in a more viewable format.
Not all patient data will be in reports…Some of the things you can find there
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Allergies (remote data)
Historical Medication Administration in the Inpatient side (BCMA reports)
Inpatient Flowsheets (Careplan, Coag, etc)
Inpatient Vitals
You may find the reports tab does not have data that every user needs, just
realize that it is there.
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This is where you’ll find remote data.
Reports Tab
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When a user first clicks on the Reports tab, the only options that are visible
are the reports and the data from the reports. When the user clicks on a
report, CPRS uses the requesters default date range setting under personal
preferences. This by default is set to the last 2 years worth of data
Once you run a report, CPRS will then ask for a data range to customize it.
The problem is that you may have to wait for 10 minutes for the first report
to run (set to the last 2 years)
In order to fix this, all users should change their default preferences. This is a
one time preference change.
Once this default setting is changed (to a shorter period of time) you can then
go back and select a date range that meets your needs.
Reports Tab Preferences
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To change personal preferences for Reports
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Select Tools
Select Personal Preferences
Click on Reports
Click on “Set all Reports” under All Reports
Change the start date to be within 14 days of today’s date
It may seem awkward at first, but when you run the report it doesn’t use those
exact dates…it uses T (today) – the number of days you set. In this example T-14
Hit OK on each screen to back out.
Report Tab Preferences Continued
When you first click on Reports Tab, you’ll
notice that you are not able to select a date range
???
Reports Tab Preferences Continued
While on the reports tab, Left click
Tools and then Personal Preferences
Reports Tab Preferences Continued
Left Click Reports
Left Click “Set All Reports”
Reports Tab Preferences Continued
Change the Start Date to 14 days
from today’s date
Hit OK
In this example, when the report
is run, it will default to T-14
Reports Tab Preferences Continued
Once you’ve actually ran a report, you can
then customize the time range
Remote Data
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If the Remote Data box is blue, there is remote data available.
Remote data is data that has been entered at another VA and that isn’t
displayed until you request it.
Allergies are a good example of remote data that you may request.
To get remote data:
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Left click the Remote Data box (if its not blue, there is no data available)
Select the sites you want data from. Usually you’d select all locations. A Check
indicates that it is selected, unchecked box means its not selected.
Once you’ve identified the sites, left click on the report you want. Portland
information will automatically be displayed and up to 30 seconds or so later, other
sites data will appear (if there is information)
Remote Data Continued
If a patient has Remote Data
The Remote Data box will be blue
Remote Data Continued
Left click the Remote Data box and Check
All Available Sites
Remote Data Continued
For Remote Allergy Data, Click the + next to
Clinical Reports and double click Allergies.
Remote Data Continued
When you first run the report, Portland data will
automatically be displayed. Wait 15 or so seconds
for other sites to load.