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 IP Location
• Find patient: EMR TEST
• Launch the Open Chart
• Click MAR
• Enter your PIN – Make sure you know your PIN
– If you need to reset your PIN – Please call the support
center x 4031
Meditech 6.0 Upgrade
RN OB/NB
Session I
Acronyms
• PCS: Patient Care System
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Care Planning
Intervention and Outcome Documentation
Medication Documentation
Notes
• MAR: Medication Administration Record
– Medication Administration Documentation
• BMV: Bedside Medication Verification
– Scanning Medication Barcodes to verify 5 Rights
• EMR: Electronic Medical Record
– Review clinical documentation
• OM: Order Management
– Enter Orders
Agenda
• PCS: Patient Care Systems
– Overview
– Status Board
– Worklist
– Care Planning
– Documentation Functions
• OM: Order Management
– How to Enter Orders
– Clinical Data Screen
• EMR: Electronic Medical Record
– Reviewing patient information
Video Demonstration I
New Admission and Care Plan Process
New Admission and Care Plan Process
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
Patient Care Routines &
Function Buttons
• ie: Psych, MedSurg, Rehab, etc
• 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
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Click [Lists]
Click [Find Patient by Inpatient Location]
Select [Test MVH IP Location]
Click [Assignments] - Right hand panel
Place a checkmark to the left of the following patient’s
names
• EMR, TESTPATIENTA
• EMR, TESTPATIENTB
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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 the card taped to your PC.
4. Click to the select the patient account
– Select the Account Number with the Admin In 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
• 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
Code Status
Allergies
Height/Weight/BSA
Admit Status
Medical Record
Number
Account Number
Worklist
OB Worklist
Worklist
Open
Chart
Routines
Worklist
Functions
• Open Chart defaults to the worklist tab
• Documentation Routine
– Interventions, Assessments, & Outcomes
Worklist: OB Standard of Care
– Upon registration a Standard of Care Automatically
defaults
– Location Specific List of Interventions
Care Plan
Adding the Plan of Care
• In Meditech, the first step for a new admission is to add the Care Plan
• Select a location specific Care Plan
– Includes Problems, Outcomes, Interventions common to any patient
admitted to the particular location
– Once the patient has been fully assessed the Care Plan will be individualized
OB Delivery Care Plan
Admission,
Physical, and
Daily
Assessments
Pain
• Location specific Care Plan includes documentation common to
any patient admitted to the particular Location
• Care Plan Components
– Admission, Daily, and Physical Assessments
– Pain
After Delivery…
The specific focus of care selection for delivery
(Vaginal, C/S, Perinatal Loss) will add:
• Appropriate Recovery Documentation
• Appropriate PP Shift Documentation
• Appropriate Teaching Records
• Discharge Documentation
Newborn Care Plan
Admission,
Physical, and
Daily
Assessments
Pain
Feeding &
Elimination
Discharge
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Location specific Care Plan includes documentation common to any patient admitted to
the particular Location
Care Plan Components
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Admission, Daily, and Physical Assessments
Pain
Feeding & Elimination
Discharge
Worklist
• Interventions and Outcomes will display on the worklist as
added with the Plan of Care
• Clicking the Frequency header will sort the list by frequencies
– This will help to clarify which interventions are to be documented
upon Admission
Video Demonstration III
Open Chart/Worklist/Add Care Plan
Open Chart Worklist Add Care Plan
Exercise C: Open Chart/Worklist/Care Plan
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Use the first TEST Patient on your PC paper
Click [Lists]
Select [My List]
From your Assignment list, click to the left of the patient’s name to
Launch the Open Chart
5. Confirm the Standard of Care list automatically defaults to the worklist
6. Click [Plan of Care] – Right Hand Panel
7. Click [Add] – Footer Button
8. Select Care Plan: OB DELIVERY Plan
9. Click [Save] – Footer Button
10. Review the Care Plan Components
11. Click [Worklist]
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Confirm the Interventions and Outcomes from the plan of care appear on
your worklist
12. Click the frequency header to sort the worklist by frequencies
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This will highlight which interventions should be documented on
admission
Admission Documentation
• The next step in the care planning process is to complete all admission
documentation and physical assessments
• Admission Assessments display separately on the worklist
– Provides clarity as to which assessments have been documented vs. those that have not
– Provides the ability to document one assessment or multiple assessments at one time
– Same assessments are documented on admission as throughout the patients stay
• Provides the ability to view documentation over time
• Provides the ability to compare the current state to the state of the patient upon admission
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 PMH
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Use the first TEST Patient on your PC paper
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. Click [Mode] to toggle to Questionnaire Mode
6. Document PMH: Asthma, Diabetes- Insulin Dependant,
Tuberculosis, Eczema, Epilepsy, Patient is not at risk for
aspiration
7. Any Body Systems with a Negative Response should be
documented as None Reported
8. Click [Save]
9. Confirm the last done column updates with the last time the
intervention was documented
EMR Patient Care Panel
• Displays PCS Documentation
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Assessments
Interventions
Outcome
Care Plan
Exercise E: Reviewing Documentation - EMR
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Use the first TEST Patient on your PC
Click [Patient Care Panel]
Confirm that the [Assessment] Tab Defaults
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
Break
1 Hour 30 Minutes
(15 Minute Break)
Individualizing the Plan of
Care
OB Individualized Focus of Care
• The Joint Commission Requires that each Care Plan be Individualized
• Individualized Focus of Care Intervention
– Tool to assist with care plan customization
– Documentation occurs
• After delivery to choose the appropriate selection
• After the admission and physical assessments have been completed, as appropriate
• When additional problems are indentified, PRN
• Based upon the selections, problems and associated interventions will be
suggested
NB Individualized Focus of Care
– Documentation on the focus of care occurs as problems
are identified, PRN
Individualized Focus of Care
• Upon saving the focus of care selections, a list of
problems is presented
– Here, Vaginal Delivery and Diabetes (GDM/IDM) was selected
Adding Problems
• Place a checkmark to the left of every Problem
presented
• Click [Ok]
OB Individualized Care Plan
• The newly added problems will be viewable within
Care Plan Routine
Documentation Frequencies
• Outcomes, Assessments and Interventions from the care plan display on the
Worklist
• Outcomes: required to be documented daily and upon discharge
• Interventions/Assessments: vary based upon protocol and physician orders
• Frequency column indicates how often to document
• Last done column indicates the last time the assessment was documented
• Frequencies can be edited as needed based upon a particular Order or Protocol
Video Demonstration V
Individualizing the Plan of Care
Individualizing the Plan of Care
Exercise F: Individualized Focus of Care
• Use the first TEST Patient on your PC
• Start from the worklist
• Find the *Individualized Focus of Care –OB
Intervention
• Click in the now column
• Click [Document]
• Select: Vaginal Delivery, Diabetes (GDM/IDM)
• Click [Save]
• A List of Suggested Problems should display
• Place a checkmark next to all and Save.
• Click [Plan of Care] – Right Hand Panel
• Confirm four new problems have been added
Individualizing the Problem and Outcome
• The next step in the care plan process will be
to further individualize the problem and
outcome
• Problem
– Indicate the specifics to which the problem relates
• Outcome
– Indicate specific goals that are being set to
achieve the outcome
Individualizing the Problem
• Once the problems have been added
• Select the Problem tab
• Click to edit the item detail field to indicate the disease
process for which the problem is related
Exercise G: Customizing the Problem
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Use the first TEST Patient on your PC
From the Care Plan Routine – Click the [Problem] Tab
Click in the item detail column for the Problem: Pain
Click [Edit] to enter text for the Problem
Indicate that this problem is “Related to vaginal
delivery, gr 3 with a peri-urethral laceration”
Click [Save]
Notice an “I” Displays in the Item detail column
Click the I to view the Item Detail
Confirm the newly documented info displays
Click [Back] to return to the plan of care
Individualize the Outcome
• Next, click the outcome tab to list the goals that will be set to
achieve the outcome
• For each outcome, click in the item detail to indicate the specific
goals will be set to achieve the outcome
Outcome Customization
• The documented goals will be viewable/editable
from the worklist
Exercise G: Customizing the Outcome
• Use the first TEST Patient on your PC
• Click the Outcome Tab to review the outcomes
• Click in the item detail column for the Outcome: Reports pain at
tolerable level
• Click [Edit] to enter text for the Outcome
• Indicate for the outcome that “Patient will demonstrate
utilization of effective comfort measures”
• Click [Save]
• Notice an “I” Displays in the Item detail column
• Click the I to view the Item Detail
• Confirm the newly documented info displays
• Click [Back] to return to the plan of care
• Click Worklist and view the item detail text to view the outcome
goals
Care Plan Process: New Admission
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Add a Location Specific Plan of Care
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Complete All Admission Documentation
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OB Delivery or Antepartum Plan
Newborn Plan of Care or NB Outside Adm
If a GYN use M/S/ICU Plan of Care
OB Arrival to Unit Admit/Transfer
OB Admission Assessment
Past Medical History
OB Adm Physical Assessment
Ht/Wt
OB Vaccine Assessment
Age 18+ Opt Out Vaccine Assessment
Braden/Skin Risk Assessment
Fall Risk/Safety/Precautions Assessment
Customize the Care Plan
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Adding Problems/Outcomes/Assessment based upon patient’s delivery status
and/or condition
Documentation Functions
Documentation Functions
• Temperature, Height and Weight Queries
– Enable you to toggle between English and Metric Units within documentation
• Instance Type Queries
– Enable multiple instances of documentation for various body locations or situations
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IV Insertions, Orthostatic Vital Signs, etc
Documentation - Calculator
• Enables you to toggle between English and Metric Units
• Regardless of the units of documentation, the display
will default to English
Documentation – Instance Type
– Enables multiple instances of documentation for various body locations,
positions or situations
• IV Insertions, Orthostatic Vital Signs
– Click the drop down arrow to invoke the group response
– Select the body location/situation
– Click Ok
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
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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Use the first TEST Patient on your PC
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
• Click [Refresh 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
• This function is enabled for a select number of assessments
• To invoke the recall values function, click the [Recall] Button
Recall Values
Recalls the entire
assessment
Recalls the section
Recalls the individual
query
• 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
• Use the first TEST Patient on your PC
• 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
Last Done
Worklist displays active and discharge statuses by default
All other statuses are suppressed from view
Status
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
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
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Use the first TEST Patient on your PC
Locate the Pain Intervention
Click the “P” to invoke the Pain Protocol
Review the Protocol
Click [Close] 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 (assessment icon) for the edit line item
to review the old and new results
Exercise J: Item Detail Text
• Use the first TEST Patient on your PC
• 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
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 PC
• Find the Vital Signs Intervention
• Edit the frequency of the intervention to .Q4H
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Click in the frequency field
Type “.Q4H”
Hit Enter
Confirm the frequency is updated
• Change the status of the Telephonic Interpretation Assessment to
Complete
– Click in the Status/Due column
– Select Complete
– Confirm the Intervention no longer displays
• Bring the Telephonic Interpretation Assessment back to active status
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Click Change View
Select Complete from the Intervention status list
Click Ok
Find the Telephonic Interpretation Assessment and click Complete
Change the status to Active
Break
3 Hours
15 Minute Break
OM/EMR Training
Agenda
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Introduction to the EMR
Allergies, Code Status
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)
Lunch Break
4 Hours
30 Minute Break
Exercise M: EMR
• Use: MTPatient,TEST
• Where are two places in the EMR that I can
find documented allergies on a patient (Hint:
Clinical data is NOT part of the EMR)?
• Where can I view the last medication
administration in the EMR (Hint: your nursing
MAR is not part of the EMR)
• How can I easily tell whether a lab is of
abnormal or critical value?
• If I want to see a trend in a patients vital signs,
how would I accomplish this?
EMR Hands-On
• Use MTPatient,Test
• What is the easiest and most succinct way to
locate a patients standard of care and
individualized plan of care?
• It is the end of your shift and you are
preparing to hand off your patient, where
would be the best place to find a
comprehensive overview of that patient for
that shift?
Allergies
In addition to the summary panel, allergies can be entered on the Clinical Data screen.
Allergies can be entered and edited by clicking the blue edit button.
Allergies cont
To add a new allergy, click the “New” tab, and free text in your entry. A list of allergies
should appear for you to select from. If your selection does not appear, the option to
add the allergy as uncoded is available, but it is important to note this selection will NOT
be included in interaction checking.
Allergies cont
Clicking on the allergy that is appropriate will launch you to the edit screen where you
will be required to enter the type allergy (or adverse reaction), status, and the reaction
associated. Allergies that are new will be highlighted on the list in green for editing. The
Audit button gives a beginning to end view of the life of an allergy including edits made
and by whom.
Allergies
• Entering and Editing Allergies
Exercise N: Allergies
• Enter a Penicillin Allergy
– Reaction: Anaphylaxis
– Severity: Severe
• Enter “Little Blue Pill” – Uncoded Allergy
– Reaction: Nausea
– Severity: Mild
• Save
• Make an edit to the little blue pill – Change to an
Adverse Reaction
• Observe the audit trail.
• Observe the status in the EMR.
Code Status
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Code status is entered as an order
– Prior Advanced Directives Documented
– Code Status
– Code Status Limits (if applicable)
– Advanced Directives Discussed and confirmed with
Code Status Order/Display
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Once the code status is entered
– Code Status displays in Patient Header
– Code Status and Limits displays in Summary Panel of the EMR
– Code Status, Limits, Advanced Directives, and Health Care Proxy display in Clinical Panel –
Code Status/Advanced Directives
EMR Summary Panel Display - Code Status and Limits
• Patient header displays Code Status
• EMR Summary Panel displays Code Status and Limits
EMR Clinical Panel Display
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Code Status/Advanced Directive Clinical Panel displays
– Code Status
– Code Status Limits
– Advanced Directives
– Health Care Proxy
Exercise: Code Status
• Use Test Patient A from your PC
• Enter a code status order
– Full Code with Limits
– Limits: No Dialysis
– Save the Order
• Confirm the Code Status Displays in the patient
header
• Review the EMR Summary Panel – Legal Indicator
Tab
• Review the Code Status Clinical Panel
Order Management
• Physicians will Go LIVE with Computerized Physician
Order Entry on July 1st
• Most Orders will be entered directly into Meditech
• In the (rare) event that the MD is not able to enter
the order into Meditech, orders may be entered for
the MD by a Unit Secretary (Non Med Orders), or
Nurse
• The next training segment will review the steps for
Entering Orders, Order Sets and Medication Orders
Order Entry- Procedures
Full orders functionality will be shown in the CBT coming up. To provide an overview, all
non ordering providers will select an ordering provider and source upon selecting “New
Orders”. This will launch you to your selection screen where you can order off of favorites,
by category group, or by typing ahead in the name tab. With the type ahead, select the
desired order. Multiple orders can be queued up by clearing the search field after selection
and typing ahead again.
Orders continued
Clicking next will launch into the Edit Order list where all new orders and any potential
duplicate orders will display. Any orders that have fields requiring edits will have an
asterisk. Clicking that order will display the edit screen and fields with asterisks must be
completed.
Editing Order Frequency
In the edit screen of an order, the frequency field can be free texted in. For
series orders, the system recognizes DAILY and QXH. Simply enter the count in
the count field and the stop time will automatically calculate. For DAILY orders
the start time automatically defaults to the morning draw. Once all
requirements are satisfied clicking next will take you to the Manage Orders
screen where additional edits can be made if necessary.
Orders cont
Once you have reviewed on Manage Orders and click next you will be taken to the
Current Orders table where new orders will be displayed with a green “New” status
until filed. Clicking submit files the orders. Physicians require pin entry before filing.
Order Sets
Order sets are available for use by nursing should it be appropriate. They are especially
useful in the ED where the Med Approved Protocols are available for use. The sets
group orders together to support evidence based medicine and can be ordered by
category or by searching by name. Multiple sets can be selected at one time.
Order Sets cont
Once the sets are selected, the manage orders list allows you to select the orders that
are needed. Edits can be made by clicking the blue edit button on an individual order
or by selecting edit all which will queue up orders for editing. The functionality here is
identical to orders and they will be filed in the same way.
Orders
• Order Management for Non-Ordering
Providers
Order Sets
• Order Sets for Non-Ordering Providers
Exercise O: Orders
•Enter orders from different categories
•Imaging, Card, US, Lab, Mic, Bloodbank, Nursing, Consults
•Make edits both individually and using “edit all”. Make one of the orders a
DAILY order by free texting in the frequency field of a routine order.
•Make note of the different screens on different types of orders.
•Enter the Admit to General Medicine Order set
•Select any orders relevant to your patient
•File all orders together.
Entering Medication Orders
• First Select Ordering Provider and Order Source and Click [Next]
• Select [New Meds]
• Type the name of the medication and select the name from the search
ahead lookup
Entering Medication Orders
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Place a checkmark next to the appropriate schedule
Click Edit to enter required information
Update the Medication Order
Click Submit and Save (or continue to enter additional medication orders
Medication Ordering Process
• One the medication orders have been entered,
pharmacy will be required to verify the orders
before they will be available on the MAR
• Once Pharmacy has verified the orders, you will
Acknowledge the Orders and document the
administrations
• MAR Documentation will be covered in session II
Exercise: Entering Medication Orders
• Enter the following Medication Orders into Meditech:
– Enoxaparin 30 mg SC Daily
– Lisinopril 10 mg PO Daily
– Furosemide 20 mg PO Daily
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Click [Orders]
Select the Ordering Provider and Source
Click [Ok]
Click [New Meds]
Use the type ahead lookup
Select the appropriate order string
Click [Next]
Edit the order information
Click [Next]
Click [Next]
Click New Med
Enter the last 2 medications and click submit at the end
Navigate to the Status Board and Select the Orders queue to confirm that
the 3 new medication orders have been entered
Consult Orders
The edit screen of a consult order differs for ordering versus non-ordering providers.
Physicians are not require to enter consulting provider, so their consults file as
incomplete to be completed by the nurse or secretary. Once the consulting provider
information is entered additional information regarding communication to the consulting
provider should be entered. A notification is sent to the physicians desktop when this
information is entered. Incomplete orders will display on the statusboard as such and on
the current orders table.
Uncollected Specimens
When a lab or micro specimen is ordered and set to be collected by the nurse, it
will flow to his/her worklist for collection. To document that it has been
collected, check in the now column and click document. If a source has not
been entered, it must be entered at this time. Filing the documentation
automatically updated the order to collected and it is filed in lab.
Consults and Specimen Collection
• Consults and Specimen Collection
Exercise P: Uncollected Specimen
• Use the first TEST Patient on your PC
• Practice entering various consult orders and
note the required fields.
• Place multiple lab and micro order set for the
Nurse to collect. Note the status of the order
on the current orders table. Collect specimen
off of worklist.
Acknowledgement of Orders
All orders and order edits must be acknowledged by nursing. The Ack
column on the status board allows for this to be done efficiently. Stat
orders will be flagged as Stat and highlighted in pink. Routine orders
will display with “Ack” in the column. Click into the column to
acknowledge.
Acknowledgement cont
Each order must be selected and reviewed individually to
acknowledge. Once you have reviewed each order, click the
Acknowledge button. To restore them to unacknowledged before filing
hit Undo. Otherwise click save to file the acknowledgment. You will
then be brought to the manage orders screen.
Acknowledging Orders
• Acknowledgement of Orders
Exercise Q: Acknowledging Orders
• Use the first TEST Patient on your PC
• Click into the Ack queue on the status board
for your patient.
• Check off each order individually.
• Review Order Detail.
• File.
Editing after Filing
To edit an existing order, click on the order in current orders, and make
any edits on the edit order list page that you are brought to. Editing a
connecting order (lab, pha, mic, rad, card) will place a stop request on
the original order and file your edits as a new order.
Editing after Filing cont
Orders can also be edited from the Edit Multiple Button located on the Current
Orders table. Multiple orders can be checked off here and edited using the
available footer buttons. Again for connecting orders, edits made to the
connecting orders (outside of the specimen collection field) will place a stop
request on the order and file the edits as a new order.
Exercise R: Editing Orders
• Use the first TEST Patient on your PC
• Make edits to both connecting (labs, mic, rad)
and non-connecting (nursing, consults, diets)
orders to observe the change in statuses.
Make note of those orders that stop request
when edited.
Requisitions
• Requisitions are a means of communication for information that is
not patient specific
• Requisitions can serve as requests for supplies or communications to
other departments
Requisitions
On the edit screen simply enter in your message/communication.
Once filed the order will print to the receiving party.
Requisitions
• Entering Requisitions
Exercise S: Requisitions
• Use the first TEST Patient on your PC
• Enter the Requisition desktop and observe the
different requisitions for the Morton facility
• Practice entering requisitions.
Suggested Orders – Nursing Documentation
• Some Nursing Documentation is set to trigger suggested orders/consults
• ie: OB Admission Assessment may trigger
– Social Services Consult, Nutrition Consult, etc
• In this case, answering yes to the nutrition consult query will trigger a
suggested order for a nutrition consult
Suggested Order
• The suggested orders screen displays
• Select the order and select Order Now or Undecided Remind
again (if not appropriate)
• To proceed to Order Management, Click Ok
Suggested Order – Order Management
• The ordering provide and source will be selected
• Manager Order fields will be documented
• And, once the order is ready to be transmitted, click Submit
Exercise T: Suggested Orders
• Use the first TEST Patient on your PC
• Document the OB Admission Assessment
– Typically, you would document all fields. For this example,
document only the information indicated below under the OB
General Information section:
– Information Provided by: Patient
– Patient Smoking Status: Never Smoked
– Nutritional Consult indicated-YES
– Patient has an Advanced Directive and it is on file from prior
visit
– Patient has a Health Care Proxy and it is on file from prior
visit
– Click Save
– You are brought to the suggested orders screen
Exercise: Suggested Orders cont’d
• From the suggested orders screen, select Nutrition Consult
and click Order Now
• Click [Ok]
• From Order Management, select the ordering provider and
the order source
• Click [Ok]
• You are launched into Order Management
• Enter the required fields (indicated by an *) and any
additional information
• Next, click Submit
• The order has been entered
• Navigate back to your status board – Click My List
• Next, Click the ACK prompt for your patient
• And, confirm the nutrition consult has been ordered
• Acknowledge the Nutrition Consult
Daily Documentation
OB Daily Documentation
• Vital Signs
• OB Shift Assessment (which includes):
– OB ADL Record
– Postpartum Assessment
– Physical Systems Assessments
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Fall Risk/Safety/Precautions Assessment
Pain Assessment
Patient Teaching
Outcome Documentation
NB Daily Documentation
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Vital Signs
Ht/Wt
NB Physical Assessment
NB Shift Care Record
NB Feeding Record
– NB Breast Milk check for dispensing EBM
• NB Elimination Record
• NB Pain Assessment
• Outcome Documentation
Physical Assessments Within Normal Limits
• For admission, the OB Adm Physical Assessment will be used
• For assessments after delivery, physical assessments will be found in the OB
Shift Assessment
– Document abnormal findings
– If the patient is within normal limits, you may use the within normal limits
statement to indicate this finding
Clinical Update Panel Comments
• Within each of the physical assessments, there is a Clinical Update Query
• This is to document notable events related to the particular body system
• This query pulls to several EMR panels & provides a snapshot of notable
events
• Supports communication between the care team members and can be
viewed in the Clinical Update Panel
OB Clinical Review Panel
• Used for information snap shot and hand-off
– Useful for nurses as well as OB’s
• Includes:
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VS
Prenatal Hx
Delivery Info
PP Assessment
PIH data
Labs
Medications
NB Clinical Review Panel
• Used for information snap shot and hand-off
– Useful for nurses as well as Pedi’s
• Includes:
– VS
– Delivery Info
– Wgt/Length/I&O
– Feeding Record
– Labs
– Medications
OB Clinical Review Panel
PP, NB and Breastfeeding Education
• Each of these interventions uses the “Instance
function” for documenting the individual topics
– This will display all of the topics that have been “covered”,
making education efforts more focused
– This information can be seen in the EMR panel:
Education Review
Documentation Example:
OB PP Education:
Topics:
OB and NB Outcome Documentation
• All outcomes are documented daily
• OB and NB outcomes have “criteria” which explain what is
meant if the goal is “met”
• Additional comments are always welcomed to make the
documentation more individual for the patient and further
explain why an outcome may not be met or only
progressing toward goal, along with any changes in the
“plan”
• The education outcome states whether education was
provided or not and there is a comment to describe
anything pertinent about the efforts to education PRN
Exercise U: Physical Assessments –
Within Normal Limits
• Use the first TEST Patient on your PC
• Place a Checkmark next to the OB Adm Physical
Assessment
• Document the Cardiovascular Assessment is within
normal limits
• Document Crackles in the left upper lobe for the
respiratory assessment
• Document the patient had wheezing that was treated by
RT at 1200 in the Clinical Updates Comment
• Document Genitourinary Assessment is within normal
limits
• Save
• Review the documentation in the M/S- Hand Off Panel
(as an example) and in the Clinical Update Panel
• Note: physical assessments do NOT go to the OB or NB
Clinical Review panels
• Vital Signs
Exercise
– Document a set of vital signs
• Teaching
– Document the OB/NB Infant Care Education
• Document that you taught the mom about Infant cues and communication and
that she verbalized an understanding of the information
• Intake and Output Assessment
– Document intake for the shift: 100 mls
– Urine Output: 50 mls from indwelling catheter
• Outcome Documentation
– Place a checkmark next to outcomes of Maternal /Fetal risk and Stable PP
recovery
– Maternal/Fetal Risk->Document “Goal Met”
– Stable PP recovery->Document “Progressing Toward Goal” with comment
“Increased bleeding in immediate postpartum, requiring additional
medication”
– Change status of Maternal/Fetal Risk to Complete as it no longer needs to be
documented
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 will
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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Use the first TEST Patient on your PC
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
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Use the SECOND TEST Patient on your PC
Find Patient by Account
Add Patient to your List
Add a new OB Delivery Plan of Care (pt is being admitted for a
scheduled C/S)
• Enter Patient Allergies and Height and Weight
• Document
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OB Arrival to Unit/Admit or Transfer
OB Admission Assessment
Past Medical History
OB Adm Physical Assessment
Select the C/S Delivery from the OB Focus of Care and add the
suggested problems
Add a new intervention: Blood Product Infusion Record/Reaction
Document Patient Teaching
Document all outcomes
Review all documentation in the Patient Care Panel of the EMR
How to Discharge a Patient:
Registration Management
How to Discharge a Patient
• The Discharge Process will be covered in session 2
– Documentation
– Reports
– Instructions
• Next, you will learn to discharge a patient from
registration management
How to Discharge a Patient
• From the main menu – select Registration
Management
Discharge Routine
• Perform a lookup to select the registration status
• Type Patient Information to identify the appropriate patient
• Click Ok
Discharge Routine
• Select the patient account from the Account
Lookup Screen
Discharge Routine
• Document the date and time of discharge and discharge disposition
• Click Next to Navigate to the next screen and document the appropriate
information
• Save
Exercise: Discharging a Patient
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Navigate to your main manu
Select Patient Registration
Select the Discharge Tab
Type: IN
Name: Use your test patient (from your PC)
Discharge Date: Today
Discharge Time: Now
Discharge Disposition: HOM
Click [Next] and enter “N” at required field
Click [Save]
Repeat process for 2nd patient used during this class
Thank you!