Transcript Slide 1
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 Patient by Inpatient Location • Select Test QMC IP Location • Find patient: EMR,TESTPATIENT • Launch the Open Chart Meditech 6.0 Upgrade Pastoral Care Session I Acronyms • PCS: Patient Care System – Assessment Documentation – Notes • EMR: Electronic Medical Record – Review clinical documentation Nursing Main Menu • List of Routines and Reports • PCS Status Board will provide most nursing care routines • Additional routines will be covered in more detail in Session II Status Board PCS Status Board Patient Assignment List Status Board Function Buttons • Patient Assignment List/Home Page • Displays Pertinent Patient Information – Relevant to the particular patient location • ie: Psych, MedSurg, Rehab, etc Patient Care Routines & Function Buttons • Continuously Refreshes with new information (every 5 minutes) • Launching pad to various patient care routines 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 • [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 Inpatient Location • Provides a list of patients admitted 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 1. 2. 3. 4. 5. Click [Lists] Click [Find Patient by Inpatient Location] Select [Test QMC IP Location] Click [Assignments] - Right hand panel Place a checkmark to the left of the following patient’s names • EMR, TESTPATIENTA • EMR, TESTPATIENTB 6. 7. 8. 9. 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 first Patient on your Blue Card 4. Click to the select the patient account – Select the Account Number with the Admin In Registration Type – The status Board will Appear • • • • 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 – – – – 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 • PCS Patient Care System EMR – MAR Medication Administration Record • Document Medications – Care Planning • Add the Care Plan – Worklist • Intervention & Outcome Documentation – Write Note • Clinical Data • Enter Allergies • Enter Home Medications • Enter/Review Patient information OM PCS Open Chart: Patient Header Location, Room, Bed Age, Sex DOB Allergies Height/Weight/BSA Admit Status Medical Record Number Account Number Worklist Worklist Worklist Open Chart Routines Worklist Functions • Open Chart defaults to the worklist tab • Documentation Routine – Interventions, Assessments, & Outcomes Adding a New Intervention • Before you may begin documenting, you must add the Spiritual Care Assessment • To add new interventions/assessments click 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 Exercise L: Adding a New Intervention • Add the Spiritual Care Assessment • From the Intervention worklist, click [Add] • Type Care and hit [Enter] – Notice the intervention does not appear • Click [Any word] – Notice Spiritual Care Assessment appears • Click the Intervention to select • Click [Save] • Confirm the Spiritual Care Assessment has been added to the worklist Documentation Overview Documentation Overview • Documentation mode defaults to flowsheet – Provides a view of prior documentation – Mode Button will toggle to Questionnaire mode • Similar to a paper assessment Documentation - Flowsheet Current Date/Time Defaults Gray Background = View Mode White Column = Documentation Mode Recall is Enabled for PMH Documentation - Questionnaire • Clicking Mode will toggle to Questionnaire Style • You may toggle between Questionnaire and Flowsheet mode at any time within documentation Video Demonstration IV Documentation Documentation Exercise D: Documenting the Spiritual Care Assessment 1. 2. 3. 4. Use the first TEST Patient on your Blue Card Start from the worklist Place a checkmark in the now column Click [Document] – Confirm the time column displays the current date/time in the header – Review the documentation • Displaying from the last admission 5. 6. 7. 8. Click [Mode] to toggle to Questionnaire Mode Document the full assessment Click [Save] Confirm the last done column updates with the last time the intervention was documented EMR Patient Care Panel • Displays PCS Documentation – – – – Assessments Interventions Outcome Care Plan Exercise E: Reviewing Documentation - EMR • • • • • • • • Use the first TEST Patient on your Blue Card Click [Patient Care Panel] Confirm that the [Assessment] Tab Defaults Click the [Name] Tab – This simplifies the list of Assessments Select to view the Spiritual Care Assessment Place a Checkmark to the left of the Assessment Name Click [View History] Confirm that all documentation displays 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 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 • • • • • • Use the first TEST Patient on your Blue Card 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 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 Worklist Management Worklist – Additional Functions Item Detail: Protocol, Associated Data, Item Detail Info Care Item: Intervention, Assessment, Outcome • • Frequency Last Done Worklist displays active and discharge statuses by default All other statuses are suppressed from view 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, Flowsheet, and Associated Data Item Detail Tabs • Detail – Info about Intervention – Intervention text (Post it note) • History – Audit trail of changes made to the intervention • Flowsheet – Documentation View in Flowsheet 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 • • • • • • • • • • • • • • Use the first TEST Patient on your Blue Card 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 • Use the first TEST Patient on your Blue Card • For the vital signs intervention, indicate that the blood pressure must be taken on the left arm – – – – – – – – – – 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 This is comparable to a post it note or Edit Text in MT Magic 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 Exercise K: Frequency and Worklist Status • Use the first TEST Patient on your Blue Card • Find the Vital Signs Intervention • Edit the frequency of the intervention to .Q4H – – – – Click in the frequency field Type “.Q4H” Hit Enter Confirm the frequency is updated • Change the status of the Age 18+ Opt Out Vaccine Assessment to Complete – Click in the Status/Due column – Select Complete – Confirm the Intervention no longer displays • Bring the Age 18+ Opt Out Vaccine back to active status – – – – – Click Change View Select Complete from the Intervention status list Click Ok Find the Age 18+ Opt Out Vaccine Assessment and click Complete Change the status to Active Break 3 Hours 15 Minute Break Add Intervention Routine • Type the name of the intervention and click enter • Select the Intervention from the List and click save OM/EMR Training Agenda • • • • • • • Introduction to the EMR Allergies, Code Status Non-Med Order and Order Set Entry Consults and Uncollected Specimens Acknowledgment and Incomplete Orders Post-Filing Edits to Orders Entering Requisitions Intro to EMR • Electronic Medical Record • Integrated system so same information is viewable regardless of point of entry or desktop • Central access point for all results, patient demographic information, reports, clinical documentation, and clinical data. Intro to EMR •Selected tabs represent the EMR, viewable from all desktops with shared information •Patient header includes name, age, DOB, ht, wt, MRN, Acct number, Reg status, location/room/bed, and allergies •Items that have information “new to you” will be highlighted in red. “i”: More Information •Small “i” next to patient name provides additional information such as allergies, height, weight, admit date and time, BMI, and Code Status. Select Visits Panel •This 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. Summary Panel •The 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. 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. Review Visit •Review 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. Notices •The 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. New Results •The 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. Clinical Panels •Clinical 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. Vital Signs •Documented 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. I&O Documented 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. Medications The 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. Medications cont The 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. Laboratory The 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. Laboratory cont Lab 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. Microbiology The 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. Blood Bank The 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. Reports The 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. Patient Care The 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. Patient Care cont Clicking 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. Notes The 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. Orders Orders 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. EMR • Electronic Medical Record (EMR) Notes Routine • Write Note provides the ability to enter free text notes • Most Documentation is included within the Assessments • Additional Information should be entered within the Assessment comments • Notes should rarely be utilized – Reserved for unusual events that are not available within the assessments – Also utilized to generate Discharge Instructions and Page 2 Reports • Be careful not to double document within the notes routine • All Clinical Documentation is viewable from within the EMR Notes Routine • To begin documenting click write note • Next, select the note category (i.e. Nurse) 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 • • • • • • • • • • Use the first TEST Patient on your Blue Card Select Write Note Select Note Category: Nurse Select the Text Button From the list of Canned Text, Select Patient Off Unit 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 Comprehensive Exercise • Document the Spiritual Care Assessment • Review all documentation in the Patient Care Panel of the EMR