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
• Click MAR
• Enter your PIN – Make sure you know your PIN
– If you need to reset your PIN – Please call the support
center 5999
Meditech 6.0 Upgrade
Interpreter Services
Session I
Acronyms
• PCS: Patient Care System
– Assessment Documentation
– Notes
• EMR: Electronic Medical Record
– Review clinical documentation
Agenda
• PCS: Patient Care Systems
– Overview
– Status Board
– Worklist
– Documentation Functions
• EMR: Electronic Medical Record
– Reviewing patient information
Interpreter Services Main Menu
• List of Routines and Reports
• PCS Status Board will provide most patient care
routines
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 QMC 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 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
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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
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
Exercise C: Open Chart/Worklist
1. Use the first TEST Patient on your Blue Card
2. You will be working with the patient from your
paper sheet
3. Click [Lists]
4. Select [My List]
5. From your Assignment list, click to the left of
the patient’s name to Launch the Open Chart
6. Confirm the Standard of Care list automatically
defaults to the worklist
Adding a New Intervention
• 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 Portuguese and she
prefers to discuss health related issues in this
language. You have been consulted and will need
to utilize the Interpretation Documentation
– From the Intervention worklist, click [Add]
– Type “Interpret” and hit [Enter]
– Select the Interpretation Documentation Intervention
– Click [Save]
– Confirm this 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
Gray
Background =
View Mode
Current Date/Time
Defaults
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
Exercise D: Documenting
1. Use the first TEST Patient on your Blue Card
2. Start from the worklist
3. Place a checkmark in the now column for the
Interpretation Documentation Assessment
4. 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. Click [Save]
7. 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 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 Interpretation Documentation
Assessment
Place a Checkmark to the left of the Assessment Name
Click [View History]
Confirm that all documentation displays
EMR Summary Legal/Indicators Panel
• Displays Language Information
Documentation Functions
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 Blue Card
Select the [worklist] routine
Select Interpetation Assessment
Click in the now column for the Interpretation
Documentation Assessment
• 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 Interpretation Documentation
displays under the adjusted time (1 hour in the
past)
• Click [Back]
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 Blue Card
• Document the Interpretation Assessment
– Click in the now column to select the intervention
– Click Document
– Click Recall
– 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
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 Blue Card
Find the Interpretation Assessment I
Click in the [Item Detail] Column
Select the [History] Tab
Select the last instance of documentation
Click [Edit]
Make an edit to the assessment
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
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
• Change the status of the Interpretation
Assessment to Complete
– Click in the Status/Due column
– Select Complete
– Confirm the Intervention no longer displays
• Bring the Interpretation Assessment back to active
status
– Click Change View
– Select Complete from the Intervention status list
– Click Ok
– Find the 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
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)
Accessing Magic From 6.0
Open the Select Visits tab of the patient’s electronic medical record (EMR)
If the patient has PCI data available, the “View PCI” footer button will be illuminated.
Clicking this button will launch you to a view only display of their PCI information in Magic.
Accessing Magic from 6.0
The patient’s PCI chart will display and can be navigated through.
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
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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
Interpreter Services Reports
• Located on the Main Menu
Comprehensive Exercise
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Use the SECOND TEST Patient on your Blue Card
Find Patient by Account
Add Patient to your List
Add a new M/S/ICU Plan of Care
Enter Patient Allergies and Height and Weight
Document
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Arrival to Unit/Admit or Transfer
Admission Assessment
Past Medical History
6 Physical Assessments
Individualized Focus of Care Intervention
Add 3 problems
Add a new intervention: CPM Continuous Passive Motion
Document Patient Teaching
Document all outcomes
Review all documentation in the Patient Care Panel of the EMR