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Before we Begin

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

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Before we Begin

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  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

  2. Meditech 6.0 Upgrade Interpreter Services Session I

  3. Acronyms • PCS: Patient Care System • Assessment Documentation • Notes • EMR: Electronic Medical Record • Review clinical documentation

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

  5. Interpreter Services Main Menu • List of Routines and Reports • PCS Status Board will provide most patient care routines

  6. Status Board

  7. PCS Status Board Patient Assignment List • 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 Care Routines & Function Buttons

  8. 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

  9. 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

  10. Video Demonstration II PCS Status Board PCS Status Board

  11. Exercise A: Find Patient by Location • 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 • 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

  12. Exercise B: Find Patient by Account • Click [Lists] • Click [Find Account] • Type Patient’s Name (Last Name, First Name) • Use the first Patient on your Blue Card • 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

  13. Open Chart

  14. Open Chart • All Inclusive Nursing Care Routine • Review Patient Data • Complete Assessment, Outcome, and Medication Documentation • Enter Orders • Enter Allergies and Home Medications

  15. 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

  16. Open Chart: Patient Header Medical Record Number Location, Room, Bed Age, Sex DOB Height/Weight/BSA Allergies Admit Status Account Number

  17. Worklist

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

  19. Exercise C: Open Chart/Worklist • Use the first TEST Patient on your Blue Card • You will be working with the patient from your paper sheet • Click [Lists] • Select [My List] • From your Assignment list, click to the left of the patient’s name to Launch the Open Chart • Confirm the Standard of Care list automatically defaults to the worklist

  20. Adding a New Intervention • Additional Interventions may be added as needed • To add new interventions use the [Add] button

  21. 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

  22. Add Intervention Routine • Type the name of the intervention and click enter • Select the Intervention from the List and click save

  23. 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

  24. Documentation Overview

  25. 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

  26. Documentation - Flowsheet Gray Background = View Mode Current Date/Time Defaults White Column = Documentation Mode Recall is Enabled for PMH

  27. Documentation - Questionnaire • Clicking Mode will toggle to Questionnaire Style • You may toggle between Questionnaire and Flowsheet mode at any time within documentation

  28. Exercise D: Documenting • Use the first TEST Patient on your Blue Card • Start from the worklist • Place a checkmark in the now column for the Interpretation Documentation Assessment • Click [Document] • Confirm the time column displays the current date/time in the header • Review the documentation • Displaying from the last admission • Click [Mode] to toggle to Questionnaire Mode • Click [Save] • Confirm the last done column updates with the last time the intervention was documented

  29. EMR Patient Care Panel • Displays PCS Documentation • Assessments • Interventions • Outcome • Care Plan

  30. Exercise E: Reviewing Documentation - EMR • 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

  31. EMR Summary Legal/Indicators Panel • Displays Language Information

  32. Documentation Functions

  33. 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

  34. Documentation – Expand/Collapse • Clicking the [-] symbol will collapse the field within the section

  35. 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

  36. Exercise F Part A: Documentation Functions - Back Documenting • 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

  37. 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]

  38. Recall Values

  39. 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

  40. Recall Values Recalls the entire assessment • 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 Recalls the section Recalls the individual query

  41. 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

  42. Worklist Management

  43. Worklist – Additional Functions Item Detail: Protocol, Associated Data, Item Detail Info Care Item: Intervention, Assessment, Outcome Frequency Last Done Status • Worklist displays active and discharge statuses by default • All other statuses are suppressed from view

  44. Item Detail

  45. Item Detail Column • Item Detail Column • P: Protocol • A: Associated Data • I: Item Detail

  46. Item Detail • Clicking the Icons will launch the item detail screen • Within Item Detail there are multiple tabs • Detail, History, Flowsheet, and Associated Data

  47. 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

  48. 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

  49. 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

  50. Item Detail: Edit Text • Enter the text that you wish to display with the intervention • Click save

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