Transcript Slide 1

Electronic Medical Record
View Access for Students
A self-paced tutorial
Student Access
Students will be given a temporary “view
only” access to the electronic medical
record
User names and passwords will be
distributed
This tutorial must be viewed prior to access
After initial login,
Select the Meditech icon
from the hospital menu
You will
automatically
begin logging into
Meditech
Meditech operates on a single click system.
Double clicking will open multiple screens and
slow down the system
Using the mouse or arrow keys,
select “Children’s Hospital
PCS”, another menu will open
Click or arrow down to
“EMR”. This is the medical
record.
A new program
window will
open,
The Enterprise
Medical Record
If you have recently
viewed medical records,
these records will
appear in a list
If no records have been
recently viewed, no
records will be
displayed
To Find a Medical Record, Search
by Location or Name
Select
“Any Location”
to search by
location
White colored
tabs are the
currently
selected tab on
the menu
Select
“Any Record”
to search by
name
“Any Location” to
Search by Location…
Then select the
desired location
A list of patients
at that location
appears,
select the
appropriate
patient
“Any Record”
to Search by Name
Then type at least:
•the first three letters of the last name
•a comma
•the first letters of first name
Then select “OK”
A list of similar
names appears,
select the
appropriate
patient
Select the
appropriate
name, using
two identifiers
(name, DOB,
medical
record
number)
Use the “Back “ button at any time to
return to the previous screen
A list of visits
for that
patient
appear; scroll
down list
The list of visits may be
narrowed by changing the
criteria, defaults to “all”
•Clinic visits are marked
with a thermometer
•Emergency Room visits
with an ambulance
•Inpatient admissions with
a bed (current visits have
a green dot by the pillow)
After Selecting a Visit,
the default
Patient Summary Screen Appears
From this
screen,
one may
access
several areas
of the patient’s
electronic
medical record
Electronic Medical Record
• In June of 2011, Children’s will move to
complete online documentation
• Until that time only particular data is available in
the electronic medical record:
– Emergency department charting
– Laboratory, microbiology, blood bank, pathology, &
imaging data
– Medications, allergies, weight & orders
– Some care provider reports (physician, social work)
Patient Header
At the top of the Patient Summary Screen is the Patient Header
The header contains
the patient name,
height, weight, body
surface area, body
mass index, & allergies
It also displays their
DOB, age, gender,
account number, medical
record number, location
The account # correlates to the visit and begins with an “H”.
The medical record # is a lifetime # and begins with an “M”
After Selecting a Visit,
the Patient Summary Screen Appears
“Summary”
view is the
default view.
Other tabs
offer other
views
Other Views
Patient Summary Screen
“Record List” takes
you back to your list of
recently viewed
records
“Other visits” goes to a
list of that patients
other visits
Tabs to the right
side of the
screen are the
medical record
menu tabs
Special Panels
Special Panels
gives the user a
central location to
view multiple data
in a spreadsheet
format
For example,
selecting
“Infectious
Disease” allows
all related data
to be displayed
Vital Signs and I & O
These categories will display recorded
nursing data.
However, at this time only the
Emergency Department
is utilizing online documentation,
therefore,
only ED information is displayed here.
Notes may be
categorized by the type
of notes available
(dark blue writing)
Notes
Select the return
button to return to
previous screen
Any note with the blue “i”
icon indicates more
information. Click on it and
the additional information
or report will be displayed
Medications
Displays active, discontinued, and all medications
ordered for patient
according to the selected panel at the top
Order History
All orders for the
patient are
displayed by
order date &
time. To change
the sorting order,
click on the
column headers
Laboratory Data
Lab data is
displayed first by
visit or lifetime
history
And also
displayed by
type of
lab test
Serial
labs are
displayed
by dates
Microbiology & Pathology
These tabs work the
same way, displaying
microbiology &
pathology tests. The
reports are displayed by
clicking on the report
icon.
Blood Bank Tests
Blood bank tests are displayed by selecting the tab
Imaging
Again, a reverse chronological list is shown of all exams.
Selecting the comment bubble in the report column
will display the written report.
Selecting the camera icon (not shown), if available,
next to the report will open
PACS, Children’s online radiological images.
Other Reports
Any report other than imaging, will appear
under this panel, such as, discharge summary,
progress notes, and history/physical.
Additional Panels
All additional panels either:
• Will not be utilized until Children’s moves
completely to online documentation
OR
• Will not be accessible by the student in
view only access.
To Complete this Module
• Please print & sign the confirmation form
and return to your instructor
• Instructors create a list of all students from
which you receive confirmation forms and
send it to:
Charlotte Simmons
Mailstop GE08
Children’s Hospital Central California
9300 Valley Children’s Place
Madera, CA 93636
Questions??
If you have questions regarding this module
or the electronic medical record, please
contact:
Patricia “PT” Lindsey, MSN, RN. CNS, CPN
@ 559-353-8112