Before we Begin Practice Logging in to ensure your password works appropriately Once you have logged...
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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
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 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 5999
Slide 2
Meditech 6.0 Upgrade Nurse Techs Session I
Slide 3
Agenda PCS: Patient Care Systems Overview Status Board Worklist
Documentation Functions EMR: Electronic Medical Record Reviewing
patient information
Slide 4
Nurse Tech 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
Slide 5
Status Board
Slide 6
PCS Status Board Patient Assignment List/Home Page Displays
Pertinent Patient Information 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 Status Board Function Buttons Patient Assignment List
Patient Care Routines & Function Buttons
Slide 7
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
Slide 8
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
Slide 9
Video Demonstration II PCS Status Board
Slide 10
Exercise A: Find Patient by Location 1.Click [Lists] 2.Click
[Find Patient by Inpatient Location] 3.Select [Test QMC IP
Location] 4.Click [Assignments] - Right hand panel 5.Place a
checkmark to the left of the following patients names EMR,
TESTPATIENTA EMR, TESTPATIENTB 6.Click [Add to My List] -Footer
Button 7.Click [Lists] - Right hand panel 8.Select [My List]
9.Confirm that both patients have been added to your assignment
list
Slide 11
Exercise B: Find Patient by Account 1.Click [Lists] 2.Click
[Find Account] 3.Type Patients 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 Click [Add to My List] Footer
Button Click [Lists] Select [My List] Confirm this new patient has
been added to your List
Slide 12
Open Chart
Slide 13
All Inclusive Nursing Care Routine Review Patient Data Complete
Assessment, Outcome, and Medication Documentation Enter Orders
Enter Allergies and Home Medications
Slide 14
Open Chart EMR Electronic Medical Record Review Patient Data OM
Order Entry Enter Orders PCS Patient Care System 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 EMR OM PCS
Slide 15
Open Chart: Patient Header Medical Record Number Account
NumberAllergies Age, Sex DOBLocation, Room, Bed Admit Status
Height/Weight/BSA
Slide 16
Worklist
Slide 17
Open Chart defaults to the worklist tab Documentation Routine
Interventions, Assessments, & Outcomes Open Chart Routines
Worklist Worklist Functions
Slide 18
Worklist: Standard of Care Upon registration a Standard of Care
Automatically defaults Location Specific List of Interventions
Includes Interventions that the CNA will need to document Provides
CNA the opportunity to document even before RN is able to add the
Care Plan
Slide 19
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
Slide 20
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 patients name to Launch
the Open Chart 6.Confirm the Standard of Care list automatically
defaults to the worklist 7.Click [Worklist] Confirm the
Interventions and Outcomes from the plan of care appear on your
worklist 8.Click the frequency header to sort the worklist by
frequencies This will highlight which interventions should be
documented on admission
Slide 21
Documentation Overview
Slide 22
Documentation mode defaults to flowsheet Provides a view of
prior documentation Mode Button will toggle to Questionnaire mode
Similar to a paper assessment
Slide 23
Documentation - Flowsheet Current Date/Time Defaults White
Column = Documentation Mode Gray Background = View Mode Recall is
Enabled for PMH
Slide 24
Documentation - Questionnaire Clicking Mode will toggle to
Questionnaire Style You may toggle between Questionnaire and
Flowsheet mode at any time within documentation
Slide 25
Video Demonstration IV Documentation
Slide 26
Exercise D: Documenting ADL Shift Assessment 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 ADL Shift Record 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.Document
the patients lunch 7.Click [Save] 8.Confirm the last done column
updates with the last time the intervention was documented
Slide 27
EMR Patient Care Panel Displays PCS Documentation Assessments
Interventions Outcome Care Plan
Slide 28
Exercise E: Reviewing Documentation - EMR Use the first TEST
Patient on your Blue Card Click [Patient Care Panel] Confirm that
the [Assessment] Tab Defaults Select to view the ADL Shift Record
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
Slide 29
Break 1 Hour 30 Minutes (15 Minute Break)
Slide 30
Documentation Functions
Slide 31
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 IV Insertions, Orthostatic Vital Signs,
etc
Slide 32
Documentation - Calculator Enables you to toggle between
English and Metric Units Regardless of the units of documentation,
the display will default to English
Slide 33
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
Slide 34
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
Slide 35
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
Slide 36
Documentation Expand/Collapse Clicking the [-] symbol will
collapse the field within the section
Slide 37
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
Slide 38
Exercise F Part A: Documentation Functions - Back Documenting
Use the first TEST Patient on your Blue Card 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
Slide 39
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]
Slide 40
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 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
Slide 41
Worklist Management
Slide 42
Worklist Additional Functions Worklist displays active and
discharge statuses by default All other statuses are suppressed
from view Care Item: Intervention, Assessment, OutcomeFrequency
Item Detail: Protocol, Associated Data, Item Detail Info StatusLast
Done
Item Detail Clicking the Icons will launch the item detail
screen Within Item Detail there are multiple tabs Detail, History,
Flowsheet, and Associated Data
Slide 46
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
Slide 47
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
Slide 48
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 patients blood pressure must be
taken on the left arm
Slide 49
Item Detail: Edit Text Enter the text that you wish to display
with the intervention Click save
Slide 50
Item Detail Text The item detail will be viewable by clicking
the I from the worklist or within the assessment
Slide 51
Video Demonstration VII Item Detail/Editing & Undoing
Documentation Item Detail Edit and Undo
Slide 52
Exercise I: Item Detail/Editing Use the first TEST Patient on
your Blue Card Locate the Pain Intervention Click the P to invoke
the Pain Protocol Review the Protocol Click [Back] 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 for the edit line item to
review the old and new results
Slide 53
Exercise J: Item Detail Text Use the first TEST Patient on your
Blue Card For the vital signs intervention, indicate that the blood
pressure must be taken on the left arm Click in the item detail
screen for the Vital Signs Intervention Click the [Detail] Tab In
the text field, click [edit] Type: Patients 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
Slide 54
Break 3 Hours 15 Minute Break
Slide 55
OM/EMR Training
Slide 56
Agenda 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
Slide 57
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.
Slide 58
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.
Slide 59
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.
Slide 60
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.
Slide 61
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.
Slide 62
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.
Slide 63
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.
Slide 64
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.
Slide 65
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.
Slide 66
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.
Slide 67
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.
Slide 68
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.
Slide 69
Medications The default on the Medications tab, is the
medication list which is a simple list of all medications during
this patients 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.
Slide 70
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.
Slide 71
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.
Slide 72
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.
Slide 73
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.
Slide 74
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.
Slide 75
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.
Slide 76
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.
Slide 77
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.
Slide 78
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.
Slide 79
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.