Transcript Meditech EMR / Open Chart - Greater Baltimore Medical Center

Meditech EMR Review
Computer Based Tutorial
Lesson Review
This lesson will describe:
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What the EMR is
Where the EMR is located
How to access the EMR
How to view results and documentation
in the EMR
What is the EMR?
• EMR stands for Enterprise Medical Record. It is
also known as “Open Chart” in Meditech,
because it is where you find your completed
documentation.
• The EMR is the place where patient
documentation and results can be accessed and
viewed, including lab/microbiology/pathology
results, the patient’s order history and
medications, reports, and a patient summary.
The EMR is accessed though the
Meditech system.
To access the EMR, you will double
click on the Meditech Icon on
your desktop.
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This will open the window where you
type your User ID and password.
Your User ID is the letter E followed by
your 5 digit employee number with no
spaces in between.
You should have chosen your
password in computer class or your
manager will help you set this up.
e12345
******
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Once you have logged into Meditech using
your login and password, you will be able to
see your Meditech desktop.
To access a patient's current visit
documentation, you will click on the PCS
Worklist button.
The EMR for previous visit information can also
be accessed through the EMR button.
To access the EMR, you can also click on
the EMR icon on the toolbar (right side of
screen) or press F11 on your keyboard.
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Once the EMR has been opened, the first screen you will
encounter is the recently accessed records list.
This screen shows you a list of patients whose records you
have viewed recently.
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You may choose a patient from this list, or use one of the
EMR panel selections on the right side menu to choose
another patient.
You will notice that when you place the cursor
over an active button, like the Any Location
button, the cursor turns into a hand with a
pointing finger. Whenever you see the cursor
turn into a hand, you will know that you are over
a “clickable” area.
To choose a patient according to where they are
located, you will click on the Any Location button.
First you will have to select the appropriate facility for
your patient. We will use Greater Baltimore Medical
Center to locate our patient.
You are presented with a list of possible patient
locations from which you must make a selection.
Our patient resides on U 48 General Medicine. We
will make that selection now.
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To select a patient, from this menu or any other
patient selection list, point anywhere within the box
with the patient’s name and click. Our practice
patient today is Apple Green. We will click on his
name now.
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You will now have the option to choose the appropriate
patient visit or encounter. Our patient has 5 recent visits
– 2 as an inpatient, 1 provider visit, 1 clinical visit, and 1
ER visit.
The icons, or pictures, to the left of each admission will
help you select the correct visit.
The patient bed is the symbol for inpatient accounts. The
green dot means that this is the current patient visit. If
there is not a green dot, it means the patient has been
discharged or that the outpatient account is not active.
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Here are some of the other symbols you may see
indicating different types of patient visits.
If you are interested in viewing a collection of
information that includes data from multiple patient
visits at once, you would click on the View All Visits
button on the EMR toolbar.
If you are interested in viewing the data from
more than one visit but not all visits, click in the
empty box to the right side of the visit to indicate
that you want to see info from that visit. Doing so
marks the box with an X, as shown here.
When an X appears in the white box, the View X
Visits becomes active on the EMR panel menu.
Clicking on that selection will present you with
information from only the visits you selected.
For this lesson, we will review the information
from the patient’s current active inpatient account.
To select this visit, we will click on the admitted
inpatient visit, highlighted here.
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Before we look into our patient’s electronic record, let’s
learn the other ways to look up a patient.
The 2nd option is by using Any Record. If you do not know
exactly where the patient is located, but DO know the name,
medical record number, social security number, or other
significant identifier, use the Any Record button.
You may use any of these fields alone or in
combination to select the patient’s record.
Some searches will be more exact than
others.
Here we will enter the patient’s
name with the last name and first
initial separated by a comma and
without any spaces.
To complete the search, we will then
click on OK.
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Our search yields one patient match.
The whole or partial name search will find every patient
with the first and last name that match the letters you
specified.
We choose the patient we want by clicking anywhere on
the name / patient record.
Once you have selected your patient and clicked on the
appropriate visit, the EMR will open on your screen.
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If there are any new results for your patient from the past 24
hours, you will first be directed to the 24 hour detail screen.
Our patient does not have any recent results, so we are
seeing the “My Panel” view.
You can learn how to build a customized My Panel by going
to the Meditech help link on the Nursing web page on the
Infoweb.
The option on the right side menu that is highlighted white
(in this case Special Panels) is the information you are
currently viewing in the center of the screen. By default, we
are viewing the My Panel section of the Special Panels.
Let’s click on Special Panels to see the other Special Panel
options.
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While in the EMR, you will notice that the upper menu options
change according to the active content on the screen.
Headers will turn white when you click on them and the
material listed in the header will show up in the middle of the
screen.
Let’s click on Cardiac and see what happens.
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Now we see the Cardiac Panels listed below the upper menu
options. If we wanted to view one of these panels, all we
would have to do is click on it and the information would
appear in the center of the screen.
Allergy Information can be found at the top of the
screen in the light blue patient information area.
To access the allergies mode, you can click on
the small blue circle and the allergy screen will
open. Let’s see what that would look like now.
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Clicking on the Allergies button will show you the allergies
that have been entered for the patient. These allergies
are checked by pharmacy for possible interactions with
the patient's ordered meditations.
You will learn more about entering allergies in the order
management lesson.
If there are new results since the last time you viewed the
patient’s information, the appropriate result titles will
appear in red in the right side panel menu.
Let’s take a look at what can be found by clicking
on different options in the menu on the right side
of the EMR.
VITAL SIGNS
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The vital signs menu option displays all recent vital sign values
that have been documented in PCS. Each column represents a
different instance of documentation.
The most recent instance appears in the far right column.
The yellow background means more detailed information
is available. You can view more information for any of
the Vital Signs parameters by clicking on them.
We will use this example to show what would happen if
we clicked on the word temperature.
The history screen for temperature shows several
days worth of data in a table format. You can easily
see changes in the temperature over time, with the
most recent results located at the top of the screen.
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Values that are out of range appear in yellow boxes.
High values will be indicated by the letter H and low
values indicated by the letter L.
On this screen we can also see the normal reference
range for the temperatures.
I&O
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The I&O panel shows the intake and output as it is
charted in PCS.
The first view shown is the 24 hour view, which is from
midnight to midnight.
To change the time view, you can click on any of the
available time frame headers at the top of the screen.
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As always, you can view more details of any data item
that has a yellow background.
Let’s see what appears when we click on Intake: Oral
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This opens up details regarding the patient’s Oral intake
documentation.
To view a complete snapshot of the oral intake
documentation, you could click on the blue circle at the end
of the row.
NOTES
The notes menu gives you the opportunity to view notes
entered by all disciplines that currently document patient
notes online.
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Some examples are nursing, physical therapy, respiratory
therapy, and nutrition.
If you only want to see notes from one discipline, you can
narrow the view on the screen by clicking on a specific header
at the top of the screen.
The Notes list is automatically sorted by date. To see the list
alphabetically, you can click on the column header “Type.”
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To read the content of a note, click on the blue circle that
appears at the end of the row.
This will open the document viewer.
With the document viewer open, you can read the note on the
screen.
You can also return to the list of notes by clicking on Return, go
back to read the previous note by clicking on Previous, advance to
read the next note by clicking on Next, or Print the note by clicking
on Print.
If you have clicked on the column header Type and rearranged your
note list alphabetically, you can also view all notes on the screen at
once by clicking on the specific note you wish to see first in the list.
We will click on the first nurse note and all notes below will open on
the screen at once.
After we click on the nurse note, it will show you the content of all
the notes at once, beginning with the note you selected. This is
useful to print when the patient is transferring to another facility.
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Remember that you will only see nursing notes when the
patient is admitted, transferred, discharged, has a change in
status, or an unusual event has occurred.
Normal nursing care is documented within interventions in
Meditech PCS.
Other disciplines will document ongoing treatments in their
notes.
MEDICATIONS
• The Medications button in the EMR is where we can see the
medications that have been entered by the pharmacy for our
patient.
• By clicking on Active, Discontinued, or All at the top of the screen,
you can narrow or expand the list to see the information you want.
• Remember the Medications list is not a replacement for
documenting on the Medication Administration Record (MAR).
• There are several ways to organize the medications view on the
screen. Clicking on the yellow headers for the columns will
rearrange the data you see below.
• Let’s see what happens if we click on the Last Admin / Dose
Admin column header.
• The medication list is now organized with the most recent
medication administration documentation at the top of the list.
• To view more details regarding a specific medication
administration, click directly in the Last Admin / Dose Admin column
and the information will open.
• Let’s click on the Insulin information to see what is hidden from
view.
• Notice any information recorded when the medication was
administered will be found on this screen.
• For Insulin, we see that the fingerstick value, administration site,
and co-signer were recorded when this medication was
administered.
• Back on the main medication view screen, any medication that is
not administered according to schedule will have a blue circle in the
Last Admin column. Clicking on this circle will open a screen where
more information can be viewed. Let’s see what this looks like
now.
• On this screen we can see that the dose was not administered.
To view the reason why the med was not given, all you would have
to do is click on the Text bubble symbol and the reason would open
on the screen.
ORDER HISTORY
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The Order History Routine shows all of the orders that have been
entered into the order entry system.
Headers across the top of the screen indicate the type of information
in each column.
The date and time on this screen indicates when the order was
entered into the computer system, not when it was performed.
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There are many ways to sort the order history list to help
you review the orders that have been placed.
To sort the list, you can click on any of the column headers
at the top of the screen.
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You can view more information on an order by clicking
anywhere on the gray portion of the row for that order.
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After clicking on an order, the details screen will appear.
The details of this order are pulled from the information
entered through the order entry system.
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We can use the back button at the top of the screen to return
to the orders screen or the Audit trail button to find out who
entered the order into the computer system.
LABORATORY
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Any available lab results will appear in blue in the
information headers at the top of the screen.
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Here we see the hematology results in the center of
the screen.
Values that are out of range appear in yellow and are
marked L for low or H for high.
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A pink box with an asterisk indicates a critical value that
demands immediate attention.
You may also see the delta symbol (triangle) for significant
change between 2 reported values.
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To see more information about any results, including the
reference range for the test, you can click on any results
with a yellow background.
We will now see what would happen if we clicked on
WBC.
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When you click on a test name with a yellow background,
it will open a result detail screen.
This screen includes the reference range for the result.
When you are finished viewing the info, you can click on
the back button at the bottom of the screen to return to
the general lab results.
In the EMR, it is possible to graph up to 3 values and visualize
their trends in graph format. Let’s learn about how to graph lab
results.
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The first step in graphing lab values is to select the results that
you wish to graph.
To do so you will use the RIGHT CLICK function on your mouse.
This means you will use your middle finger instead of your pointer
finger to click with the mouse.
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In our example, we will point to the Hct box with the mouse and
RIGHT CLICK to choose it as a graph value.
The Hct box becomes green, indicating it has been selected. Now
we will click on Toggle for Graph to select this value for graphing.
Next we would RIGHT CLICK on Hgb. Once the 2 results are
selected we are ready to graph.
We will then click on Graph from the bottom menu to make the
graph.
The 2 values are
then shown in a
graph format on
the screen.
The legend at the
top shows how
many days worth
of information you
are viewing in the
graph.
You can change
the graph view by
clicking on
another header at
the top of the
screen.
When you have finished viewing the graph, you can click the
cancel button to return to the lab results screen.
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Whenever you see a text bubble in the results, you will
know there is a result that is too large for the results box.
Clicking on the text bubble allows you to view the details of
the results.
MICROBIOLOGY
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Microbiology results are available in 2 formats: report or
grid.
To view the different types, you will click on the symbol
in the Report/Grid box.
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We will first look at the report format.
The microbiology report offers the most detail about
the patient and specimen.
To open the report, we will click on the report icon.
This report can be printed
and manipulated using the
icons in the top left corner of
the screen or the Print
button on the right side
menu.
To close the report viewer
and return to the EMR, click
the Return button on the
right side of the screen.
To open the grid format of a microbiology report, we will
click on the grid icon.
The grid format offers a graphic representation of the
resistances and susceptibilities reported for the specimen.
To return to the main microbiology screen, we can click on the
Back button at the bottom of the page.
BLOOD BANK
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The blood bank button will open the section of the EMR that
displays all blood bank results and information.
You can click on the headers at the top of the screen to narrow
or expand the blood bank information you are seeing in the
middle of the screen.
PATHOLOGY
The Pathology Screen looks very much like the
Microbiology Screen. To view a Pathology report,
you will click on the report icon to the right of the
name of the specimen.
IMAGING
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Transcribed reports from diagnostic imaging are available
through the imaging selection on the right side menu.
Here you can read reports for MRIs, x-rays, CT scans,
ultrasounds, and any other imaging reports.
To view a report, you can click on the text bubble located in
the report column for the report, and the report will open on
the screen.
OTHER REPORTS
The Other Reports menu button offers direct access to
dictated physician reports such as history & physicals
and consults.
The first view you will see when you click on the Other
Reports button is the All Reports view, which includes a list
of details about every report available in this section.
You can narrow the view of the reports you are seeing by
clicking on a specific header at the top of the screen – and
those particular reports will then appear below in the main
screen.
To view a report, you can click on the text bubble located in
the report column for the report, and the report will open on
the screen.
Once you have viewed a report, a check mark will appear in the
bubble showing the report has been viewed.
The status column will show if the report is still in draft form or
if it has been signed.
CARE TRENDS
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Care Trends shows you a variety of documentation, grouped
according to body system.
If you are interested in a certain body system, you can click on it
in the header menu at the top of the screen. Here we have
clicked on the HEENT header.
If there are new results you have not viewed yet, the header will
be red.
CARE ACTIVITY
Care activity lets you view completed documentation,
including Assessments, Interventions, Outcomes, and
Plans of Care in one place.
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The first view you will see in Care Activity is the Spreadsheet
view.
You will notice the spreadsheet header highlighted at the top
of the screen.
the last three Interventions documented will appear expanded
at the top of the spreadsheet view as we see here.
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The spreadsheet view is very useful in trending patient data.
You can view up to 3 interventions trended at one time at the top of the
screen.
To open certain Interventions at the top of the screen, you will RIGHT
CLICK on them at the bottom of the page to highlight them.
After your selected Interventions are highlighted, you will click on the
Display button at the bottom of the screen and the Interventions you
have highlighted will open at the top of the page.
You can also click on the Date header to organize the Care
Activity screen. It will arrange the list with the most recent
documentation near the top of the page.
In the Date view, there are 4 headers at the top of the screen:
Assessments, Interventions, Outcomes, and Plan of Care.
Under the Assessment Header, you will find any
documentation completed in PCS that has an additional
assessment screen attached to the documentation.
To view the documentation, you would click on the blue circle
at the end of the row and a snapshot of the documentation
would open.
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Any “I Did Its” that have been documented in PCS show up
under the Interventions header in Care Activity.
An “I Did It” is a reminder for the nurse or tech to do
something. It appears on the Nurses’ intervention list in PCS
with an asterisk behind the Intervention’s name.
Care Plan Outcome documentation will show up under the
Outcomes header.
When a new care plan or problem is added to a patient in PCS,
it will appear under the Plan of Care header.
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Another way to sort the list in Care Activity is by using the Name
Header. Clicking on name will bring up a list of all the intervention
names.
If you click on a certain intervention name, it will open up all
documentation for that intervention in order of the date of
documentation.
Let’s see what would happen if we clicked on Vital Signs: Adult
This opened up a view where we can see all the vital signs
documentation. To view a certain episode, we would then click
on the blue information icon to the right of the row.
Under the blue information icon is a snapshot of the
documentation.
You can use the Earlier and Later buttons at the bottom
of the screen to scroll through previous and following
episodes of documentation.
The back button will take you back to the general
Intervention Name list.
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The final way of viewing documentation in Care Activity is by clicking on
the Recorded By header.
This view is helpful if you are looking for documentation that was
recorded by a certain staff member.
This can be helpful to search for your own documentation or the
documentation of a certain discipline (for example – respiratory therapy).
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By clicking on a specific user’s name, you can pull up only
that person’s documentation.
Here we will choose a user and click on their name.
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This will pull up a list of all of the user’s documentation.
To view the actual documentation, we would click on the blue
information icon to the right of the row.
HISTORY
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The first view you will see when you click on History is all the
positives that have been documented in the Patient’s Past
Medical History in PCS.
If you are searching for abnormal patient history data, this is
the best place to start.
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The history can also be grouped according to body system
by clicking on one of the headers at the top of the screen.
In this example, we have clicked on Psychosocial at the
top of the screen and we are now only seeing that piece of
the history below.
SUMMARY
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The summary screen houses a variety of information, from
demographics to insurance details.
Whenever a header is visible at the top of the screen, you
know that information is available on that topic.
To access the info, click on the appropriate header and the
information will show below in the main screen.
Now let’s discuss what the icons in the bottom right
corner of the EMR stand for.
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The first icon is a Question Mark.
You can click on the question mark icon to access the help
mode to learn more about using the EMR and its features.
The next icon is a picture of the world. When you click on this button
it will allow you to select a link to view the resident patient list.
The next link is a picture of a printer. Whenever you
wish to print a screen in the EMR, you can click on this
icon.
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You can use the suspend icon to temporarily log out of Meditech.
Let’s see what happens when we click on the suspend icon.
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The screen will be hidden from view.
After you have clicked on the suspend icon, the user will be
required to input their password again to log back in.
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The suspend function is for temporary log outs only.
Do not use suspend if you want to log all the way out of
Meditech.
Finished?
• Remember that is is very important to
exit the system completely when you
are finished viewing patient
information.
• This is both a GBMC requirement
and a HIPPA requirement.
To exit out of your EMR session completely, use the black
X in the upper right hand corner or click on the Record List
button and then “Exit PCS” to exit.
When you are back on your Meditech
desktop, you will click on the red X from
the right side menu to log completely out
of the system.
Need More Help?
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GBMC has Meditech Help Manuals and Information on the
Infoweb.
To find the help section, click on the Nursing link in the green
toolbar at the top of the Infoweb homepage.
Once the nursing page opens, scroll all the way
down to the bottom and you will see the Meditech
Help Link and User manuals.
Great Job!
• You have successfully completed the
EMR tutorial.
• Don’t forget to use the Meditech Help
Link on the Nursing web page of the
Infoweb to find extra tips and help.