Transcript OM/EMR Training

OM/EMR Training
Agenda
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Introduction to the EMR
Non-Med Order and Order Set Entry
Consults
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 Progess 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 Hands-on
• 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
• What is the easiest and most succinct way
to locate a patients all of the assessments
and interventions that have been
documented?
• 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?
• Where do you go to find physician reports
and can you print these reports?
Code Status
Code status can only be entered on the patient data screen of the Clinical Data
Screen. Code status can be selected from a list of options and limits can be
entered below if appropriate. This information can be viewed here as well as in
the Kardex, the small “i” next to the patient’s name in the header, and in certain
clinical panels.
Hands on Exercises
• Enter Code status on your patient and
observe the status in the EMR. Edit this
status and note the update in the 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.
Order Entry- Procedures
Full orders functionality will be shown in the CBT coming up. To provide an
overview, all nonordering providers will select an ordering provider and source upon
selecting “New Orders”. This will launch you to your selection screen where you can
order off of favorites, by category group, or by typing ahead in the name tab. With
the type ahead, select the desired order. Multiple orders can be queued up by
clearing the search field after selection and typing ahead again.
Orders continued
Clicking next will launch into the Edit Order list where all new orders and any
potential duplicate orders will display. Any orders that have fields requiring edits
will have an asterisk. Clicking that order will display the edit screen and fields with
asterisks must be completed. Once these requirements are satisfied clicking next
will take you to the Manage Orders screen where additional edits can be made if
necessary.
Orders cont
Once you have reviewed on Manage Orders and click next you will be taken to
the Current Orders table where new orders will be displayed with a green “New”
status until filed. Clicking submit files the orders. Physicians require pin entry
before filing.
Order Sets
Order sets are available for use by nursing should it be appropriate. They are
especially useful in the ED where the Med Approved Protocols are available for
use. The sets group orders together to support evidence based medicine and
can be ordered by category or by searching by name. Multiple sets can be
selected at one time.
Order Sets cont
Once the sets are selected, the manage orders list allows you to select the
orders that are needed. Edits can be made by clicking the blue edit button on an
individual order or by selecting edit all which will queue up orders for editing.
The functionality here is identical to orders and they will be filed in the same
way.
Orders Hands-on
•Enter orders from different categories
•Imaging, Card, US, Lab, Mic, Bloodbank, Nursing, Consults
•Make edits both individually and using “edit all”
•Make note of the different screens on different types of orders.
•Enter the ED RN Protocol Abdominal Pain set
•Select any orders relevant to your patient
•Use appropriate order sources (MECC Approved Protocol for ED RN Protocol
sets).
Consult Orders
The edit screen of a consult order differs for ordering versus non-ordering
providers. Physicians are not require to enter consulting provider, so their
consults file as incomplete to be completed by the nurse or secretary. Once the
consulting provider information is entered additional information regarding
communication to the consulting provider should be entered. A notification is sent
to the physicians desktop when this information is entered. Incomplete orders will
display on the statusboard as such and on the current orders table.
Hands on exercise
• Practice entering various consult orders
and note the required fields.
Acknowledgement of Orders
All orders and order edits must be acknowledged by nursing. The Ack column
on the statusboard allows for this to be done efficiently. Stat orders will be
flagged as Stat and highlighted in pink. Routine orders will display with “Ack” in
the column. Click into the column to acknowledge.
Acknowledgement cont
Each order must be selected and reviewed individually to acknowledge. Once
you have reviewed each order, click the Acknowledge button. To restore them
to unacknowledged before filing hit Undo. Otherwise click save to file the
acknowledgment. You will then be brought to the manage orders screen.
Hands on Exercise
• Click into the Ack queue on the
statusboard for your patient. Review and
check off each order individually. File.
Editing after Filing
To edit an existing order, click on the order in current orders, and make any edits
on the edit order list page that you are brought to. Editing a connecting order
(lab, pha, mic, rad, card) will place a stop request on the original order and file
your edits as a new order.
Editing after Filing cont
Orders can also be edited from the Edit Multiple Button located on the Current
Orders table. Multiple orders can be checked off here and edited using the
available footer buttons. Again for connecting orders, edits made to the
connecting orders (outside of the specimen collection field) will place a stop
request on the order and file the edits as a new order.
Editing Orders Hands on
• Make edits to both connecting (labs, mic,
rad) and non-connecting (nursing,
consults, diets) orders to observe the
change in statuses. Make note of those
orders that stop request when edited.
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 Hands-on
• Enter the Requisition desktop and observe
the different requisitions for the Quincy
facility. Practice entering requisitions.