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.MOH Location
• Find patient:
• Launch the Open Chart
• Select to suspend your session
• Enter your PIN – To re launch the session
– If you need to reset your PIN – Please call the support
center 5999
Meditech 6.0 Upgrade
Dietary
Session I
Acronyms
• PCS: Patient Care System
– Intervention and Assessment Documentation
– Notes
• EMR: Electronic Medical Record
– Review patient information
• OM: Order Management
– Review Orders
Agenda
• PCS: Patient Care Systems
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Overview
Status Board
Worklist
Care Planning
Documentation Functions
• OM: Order Management
– Enter Orders
– Clinical Data Screen
• EMR: Electronic Medical Record
– Reviewing patient information
• ITS: Imaging and Therapeutic Services
– Charge Entry
Registered Dietician Main Menu
• List of Routines and Reports
• PCS Status Board will provide most nursing care
routines
RD Main Menu
• PCS Status Board
• Desktop – Patient Care Routines
• Patient Data Screen (Tech Desktop)
• Reconciliation Menu
– Therapists Desktop – Charge Entry
– Reconciliation Reports
– Billing Reports
• Dietary
– List of Dietary Reports
• Nutrition Custom Reports
– List of Custom Dietary Reports
PCS: Patient Care Systems
Status Board
Status Board/My List
Patient
Assignment
List
Status Board
Function
Buttons
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Patient Assignment List/Home Page
Patient Care Routines &
Displays Pertinent Patient Information
Function Buttons
– Relevant to the particular patient location
• 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
– 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.MOH Location]
Click [Assignments] - Right hand panel
Place a checkmark to the left of your TEST patient’s
name
Click [Add to My List] -Footer Button
Click [Lists] - Right hand panel
Select [My List]
Confirm the patient has been added to your
assignment list, then remove
Exercise B: Find Patient by Account
1. Click [Lists]
2. Click [Find Account]
3. Type Patient’s Name (Last Name, First Name)
– Use your TEST patient
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 Patient Care Routine
– Review Patient Data
– Complete Assessment Documentation
– Enter Orders
Open Chart
• EMR Electronic Medical Record
– Review Patient Data
• OM Order Management
EMR
– Review Orders
• PCS Patient Care System
– Worklist
• Intervention/Assessment Documentation
– Write Note
• Clinical Data
• View Allergies
• View 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
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Open Chart defaults to the worklist tab
Documentation Routine
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Interventions, Assessments, & Outcomes
Worklist is shared by all Care Providers
Care Items display based upon Care Provider Type
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PT Assessments display for Physical Therapist
OT Assessment Display for Occupational Therapists
SLP Assessments Displays for Speech Language Pathologists
Adding a New Intervention
• Interventions may be added to the worklist
• To add new intervention or set 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 Intervention Name
• Select the Intervention
• And click save to add to the worklist
Exercise: Adding a New Intervention
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Use your TEST patient
From the Worklist, click [add]
Select the [Any Word] tab
Type Nutrition
Hit [Enter]
Select the Nutrition and Follow Up Assessment
Click Save
Confirm that the Interventions displays on the
worklist as expected
Worklist
• Interventions/Assessments will display on the worklist
to be documented
• The worklist is clickable and sortable
• Click any of the worklist headers to sort the list
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
White Column =
Documentation
Mode
Gray
Background =
View Mode
Recall is
Enabled for
PMH
Current Date/Time
Defaults
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: Document Nutrition Assessment
1. Use your TEST patient
2. Start from the worklist
3. Place a checkmark in the now column for the Nutrition
Assessment
4. Click [Document]
– Confirm the time column displays the current date/time in the
header
– Review the documentation
• Displaying from the last admission
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Click [Mode] to toggle to Questionnaire Mode
Document and click save
Click [Save]
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: Reviewing Documentation - EMR
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Use your TEST patient
Click [Patient Care Panel]
Confirm that the [Assessment] Tab Defaults
Select to view the Nutrition Assessment
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
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
• You may repeat the instance type documentation for the new
body location
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
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Notice the temperature section is now collapsed
You may now click the [+] symbol to expand
Some sections will default as collapsed
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 Part A: Documentation Functions Back Documenting
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Use your TEST patient
Select the [worklist] routine
Select Nutrition Asssesment
Click in the now column for Nutrition 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
• Document
• Save
Exercise: Review Documentation in EMR
• Select [Patient Care Panel] in the EMR
• Place a checkmark to the left of the Nutrition
Assessment
• Click View History
• Confirm that the Nutrition Assessment displays
under the adjusted time (1 hour in the past)
• Click [Back]
Recall Values
Care Plan
Care Plan/Goals/Plan
• Nutrition Goals and Nutrition Plan are documented
within the Nutrition Assessment
• The Nutrition Goals section is an Instance Type
– Multiple goals can be initiated and assessed
Dietary Goals Documentation
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Free text the short term goals in the instance field
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Liquid Diet
Next you will document the time frame
Also, you will document the progress
The Rehab Goals Documentation will appear in the EMR
Exercise: Documenting Patient Goals and
Rehab Treatment Plan
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Document the Nutrition Assessment
Place a checkmark in the now column
Click Document
Click Mode to toggle to questionnaire mode
Scroll to the bottom of the assessment and find the
Nutrition Goals
6. Indicate two nutrition goals
1. Click new short term goal to start an instance and free
text the first goal
1. Document the assessment
7. Document the nutrition treatment plan
EMR Display: Nutrition Goals
• Nutrition Goals will be viewable in EMR
– Clinical Panels
EMR Display: Nutrition Goals
• Dietary Goals will display in the Nutrition
Summary Clinical Panel
Exercise: Review Goals and Plan in the EMR
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Review the nutrition goals in the EMR
Refresh EMR
Click Clinical Panels
Select Nutrition Goals
Confirm the documentation from your Nutrition
Assessment displays as expected
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
Exercise J: Item Detail Text
• Use your TEST patient
• For the nutrition intervention, write a note that the next care
provider may need to know
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Click in the item detail screen for the Nutrition Assessment
Click the [Detail] Tab
In the text field, click [edit]
Type a free text note
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
Video Demonstration VII
Item Detail/Editing & Undoing Documentation
Item Detail Edit and Undo
Exercise: Editing Documentation
1. From the Worklist, Select the last done field for the
Nutrition Assessment
2. Select the last documented line item
3. Select the [Edit] button
4. Make an edit to your last documented assessment
5. Click [Save]
6. Note the new Edit Line Item
7. From the history tab, click the detail tab for the edit line
8. Review the “Old” Assessment and the “New” Assessment
9. The new (most accurate) assessment displays in the EMR
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
Undoing Documentation
1. From the Worklist, Select the last done field for the
Nutrition Assessment
2. Select the last documented line item
3. Select the [Undo and Save] button
4. Select the Reason for Undo
5. Note the new Undo
6. From the history tab, click the detail tab for the edit line
7. Review the “Old” Assessment
8. This assessment has been stricken from the record and no
longer displays in the EMR
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: Intervention Status
• Change the status of the Nutrition Assessment to
Complete
– Click in the Status/Due column
– Select Complete
– Confirm the Intervention no longer displays
• Bring the Nutrition Assessment back to active
status
– Click Change View
– Select Complete from the Intervention status list
– Click Ok
– Find the Nutrition Assessment and click Complete
– Change the status to Active
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. RD)
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: Notes Routine
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Use your TEST patient
Select Write Note
Select Note Category: RD
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
Patient Reports
• Standard Meditech Reports
Pulled from the Status Board
Patient Reports
• This will launch you to the reports routine
You will define the report format and
date and time to run the report
Examples of Patient Reports
• Nutrition Assessment & Follow Up
• SLP Bedside Evaluations/MBS
Exercise: Patient Reports
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Navigate to the status board
Click Patient Care Reports
Place a checkmark to the left of your patient’s name
Click Reports
Select the drop down arrow
Click next until you find the Nutrition Assessment &
Follow Up Report
7. Select this report from the list
8. Select start date T-1
9. Click Ok
10. Select Ok to preview the report
Break
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)
Lunch 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?
• On the day of go live, where should you go to
find all scripts reports?
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 Blue Card
• Enter the Requisition desktop and observe the
different requisitions for the Quincy facility.
Practice entering requisitions.
Suggested Orders – Nursing Documentation
• Some Nursing Documentation is set to trigger suggested orders/consults
• ie: 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 Blue Card
• Document the Admission Assessment
– Typically, you would document all fields. For this example,
document only the information indicated below:
– Primary Language: English
– Chief Complaint: Chest Pain
– Information Provided by: Patient
– Patient Smoking Status: Never Smoked
– 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
– Patient has unintentionally lost 10 pounds in the last 6
months and a Nutrition consult should be ordered
– Click Save
– You are brought to the suggested orders screen
Exercise: Suggested Orders
• Use the first TEST Patient on your Blue Card
• From the suggested orders screen, select Nutrition Consult and
click Order Now
• Click Ok
• From Order Management, select the ordering provide 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
M/S Hand Off Clinical Panel
• The Clinical Update Comments (documented within the Physical
Assessments) will be viewable from the MS Hand Off Panel to assist
with hand off communication
Patient Teaching
• Health Medication/Education – Teach Record
• Document all patient teaching from this Outcome
• This assessment is available for all disciplines
Outcome Documentation
• All outcomes are documented daily
Exercise U: Physical Assessments – Within
Normal Limits
• Use the first TEST Patient on your Blue Card
• Place a Checkmark next to Respiratory Assessment,
Cardiovascular Assessment, and Genitourinary
Assessment
• Document the Cardiovascular Assessment is within
normal limits
• Document Genitourinary Assessment is within normal
limits
• Document Crackles in the left upper lobe for the
respiratory assessment
• Document the patient had boughts of apnea during
lunch in the Clinical Updates Comment
• Save
• Review the documentation the M/S- Hand Off Panel
Exercise
• Vital Signs
– Document a set of vital signs
• Teaching
– Document the Health Medication/Education – Teach Record
• Document that you taught the patient’s wife about infection control
precautions
• 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 each of the outcomes and document
together
– Document for each outcome that the patient is progressing toward the
goal
– And, for the Alteration in Health outcome, document a comment
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