Before we Begin Practice Logging in to ensure your password works appropriately Once you have logged...

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

Meditech 6.0 Upgrade Nurse Techs Session I

Agenda PCS: Patient Care Systems Overview Status Board Worklist Documentation Functions EMR: Electronic Medical Record Reviewing patient information

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

Status Board

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

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

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

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

Open Chart

All Inclusive Nursing Care Routine 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 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

Open Chart: Patient Header Medical Record Number Account NumberAllergies Age, Sex DOBLocation, Room, Bed Admit Status Height/Weight/BSA

Worklist

Open Chart defaults to the worklist tab Documentation Routine Interventions, Assessments, & Outcomes Open Chart Routines Worklist Worklist Functions

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

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

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

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 White Column = Documentation Mode Gray Background = View 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

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

EMR Patient Care Panel Displays PCS Documentation Assessments Interventions Outcome Care Plan

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

Break 1 Hour 30 Minutes (15 Minute Break)

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 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 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

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 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

Worklist Management

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

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 patients 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 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

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

Break 3 Hours 15 Minute Break

OM/EMR Training

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

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 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.

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)

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