Transcript The Initial Patient Encounter - Greater Baltimore Medical

The Initial Patient Encounter
PCS Lesson 2
Objectives
This lesson will describe:
• The process by which you document a
patient’s admission
• The purpose and selection of Standards of
Care
• The features of your Intervention worklist
• How to document on a variety of screen
types
• How to change the status of completed
interventions
We will begin by assuming that we just received a new
admission who we have added to our status board. Our new
admission is Blake Mobley.
The first thing we must do to begin documenting on our new
patient is click anywhere in the patient row, as highlighted
above. Let’s see what would happen if we do this.
Clicking on the patient record will cause the row to become
highlighted blue. It is very important we always double check
to make sure we have selected the correct patient to
document on.
Another way of making sure we have selected the correct
patient is that his / her name appears at the top of the screen
in light blue.
Once you have clicked on your patient and their name is
highlighted, you are ready to begin your admission
documentation. To start this process, we will click on the
Interventions button on the right side panel menu.
Our patient does not have any interventions because he is a
new admission. To add interventions, we must click on the
“Add Interventions” button at the bottom of the screen.
The Intervention Multi-Select Window will automatically
appear. For any admission, the very first thing you do is add a
Standard of Care.
Standards of Care (SOC) are predefined sets of tasks that
are performed for all patients on your unit. Every patient will
be assigned the appropriate SOC for his / her admission in
order to initiate the various assessments that are to be
documented during the patient’s hospital visit.
To add a Standard of Care to the patient, begin typing SOC in
the data entry field of the Intervention Multi-Select window, as
shown here.
As you type, all of the SOCs will appear in the Multi-Select
window. As you can see, there is a large variety of SOCs from
which you can choose.
Our patient is an adult Med/Surg patient, so we will select the
SOC: Med/Surg Adult to add to his Intervention List. To select
the desired Standard of Care for our patient, we will click in
the empty box to the left of the Intervention name. This will
create a check mark in the box, as we see on the screen
here.
Always make sure your Standards of Care that you want to
add have been check-marked. It is not enough to click on the
name of the SOC to highlight it blue. Without the checkmark,
nothing will be saved. We will add this SOC to our patient by
clicking on Add and Exit in the upper right hand corner of the
Intervention Multi-Select window.
This will add the SOC to your Intervention Worklist. The
Intervention Worklist is where we will document the cares we
provide for our patients.
One thing we notice on our screen is that the Interventions
added when we selected a Standard of Care for our patient
are the color purple. This is an indication that they have not
been saved yet. To save this Standard of Care to our patient,
we must click on the word File, found in the upper right hand
corner of the screen. Let’s see what happens when we do
that.
You can see that once we file or save the Standard of Care,
the Interventions for our patient no longer appear purple. Let’s
discuss what we are seeing on our Intervention Worklist.
At the very top of our Intervention Worklist for our patient we
see the Document Stamp. The Document Stamp will allow us
to retrospectively document Interventions. We are required to
back-time our documentation if the care occurred over one
hour in the past. For example, if we take a set of vital signs at
9:00 am, we have until 10:00 am to get those vital signs into
the computer system without changing the time in the
document stamp. We will learn how to back-time our
documentation using the document stamp in a separate
lesson.
The first column in the
Intervention Worklist is the
Intervention column. Each
intervention we have added
as part of the Standard of
Care displays here.
The next column in the
Intervention Worklist is
the Text/Ord column. The
text bubble will show if an
Intervention has text
added to it. Text can be
pre-built or will flow over
from order entry. To add
and edit text, you can
click directly in the
text/ord column.
The Status column will show
whether an Intervention is Active,
Complete, or Inactive. An
Intervention with an Active (A)
status is one that we will routinely
be using to document with. Once we
have finished documenting on an
intervention, we can change the
status to Complete (C). We will
learn more about how to utilize this
column later in the lesson.
The Src, or Source column, will
show where the Intervention was
added from. All of our Interventions
were added as a SOC from PCS, so
we see a source or PS. Other
sources we may see are OE – from
Order Entry, and ED – from the
Emergency Department.
The Frequency column shows
the minimum amount of times
the Intervention must be
documented. The
Interventions with a frequency
of “On Admission” are the first
Interventions we document as
part of the admission process.
In future lessons we will learn
how to document the others.
To change a frequency of an
Intervention, we can click
directly in the Frequency
column. Let’s see how we
would do this for our Height
and Weight Intervention by
clicking in the Frequency
column for Height and Weight.
Clicking in the frequency column will open a screen where we
can edit the frequency. To begin this process, we must first
click on the Add button.
This will pull in the current date and time. Next we have to
add our new frequency in the blank frequency box.
F9
We want to add a nursing frequency of NURBID to our
intervention. To add a nursing frequency, we will type a capital
latter N in the frequency box and then press the F9 key on
our keyboard to see our list of frequency options.
Our list of nursing frequencies will appear. Here we have
clicked on the one we were looking for – BID Twice a day.
Now we must click on the Update button to update our new
frequency choice on the screen.
Now our new frequency has been added to the top of the
screen. We now must click on OK to change our frequency
back on the Intervention List.
We are now back on our Intervention List. Notice the
frequency column for height and weight is green. This means
we have to file our new frequency changes. After we file
them, we will be able to see the changes reflected in the
Frequency column.
We have now filed our Intervention worklist and the new
frequency of NURBID is showing up in the frequency column
for height and weight.
The History column shows us
when each of the Interventions
was last documented in minutes,
hours, or days. We have not
documented on any of our
Interventions, so we are not
seeing anything in our history
column yet. The History column
is also the place where we will
edit or correct any mistakes in
our documentation. We will learn
more about documentation
editing in another lesson.
The Next Scheduled Column
shows us the next two times an
Intervention is due to be
documented on within the next
24 hours. We will only see these
times in the next scheduled
column for Interventions with a
frequency that Meditech
recognizes as a certain time.
The Prtcl, or Protocol Column,
will display a triangle symbol if
the Intervention has an attached
policy / protocol that may be
useful when documenting. To
view the protocol for an
Intervention, we will simply click
on the Protocol Triangle.
The Assoc Data column will pull
recent documentation from the
EMR / Chart and display it on
the screen. To view the recent
documentation, all we have to do
is click on the triangle in the
appropriate Assoc Data column.
The Intervention worklist is
arranged in order according to
the frequencies of the
Interventions. The
Interventions due soonest are
found at the top of the list,
followed by those due On
Admission, and finally – those
listed as PRN, On Discharge,
and any other frequency.
We can also sort out Intervention list alphabetically. This is
often helpful if we have several interventions on our worklist
for a patient. To alphabetize your Intervention worklist, you
will click on the column header where it says Intervention.
Let’s see what this looks like.
We can now see our
Interventions listed in
alphabetical order from A to Z
on this screen.
To change the screen back to
being ordered according to
frequency, all you have to do
is click on the Next Scheduled
Column and the list will
rearrange.
In this lesson, we are admitting a Med/Surg patient, but the
process for patients of all types are similar to this one. We will
first document all those items with a frequency of “On
Admission.”
There are two sets of documents that need to be completed
within 24 hours of admission. The first set is the Admission
Database and the second set is the past medical history.
We will also need to document on our System Flowsheet.
This is your patient’s head-to-toe assessment, and is
documented upon admission and at regular intervals during
the hospital stay.
When we are ready to document something, we can open the
documentation screen in one of two ways. One way is by
clicking on the Intervention name one time so that it is
highlighted (as we see on this screen for our Med/Surg
System Flowsheet) and then clicking on the word Document
at the bottom of the page.
After you click on Document, you
will have to select the date and time
you performed the assessment. If
your documentation is within an
hour of the time you actually
performed the assessment, you can
simply click on OK at the bottom of
this window. Otherwise, the date
and time will need to be changed to
reflect the accurate time the
assessment was performed.
After you have selected a
date/time, the “Go To” List will
open on the screen. The patient
System Flowsheet and the Past
Medical History are called Group
Assessments. This means they
have several pieces that must be
documented. We will see this
“Go To” window open for either
of these Interventions when we
are documenting on them. For
our Med/Surg System
Flowsheet, we will start at the
top by clicking on Neurological
and work our way down the list.
This is the documentation screen that addresses the
patient’s neurological status. There are several
different types of questions you must answer. Every
color on this screen has a meaning. We will explain
the color scheme and how to answer the questions as
we proceed.
The first question is about the patient’s LOC. On the
left side of the screen is what you are documenting –
in this case the patient’s level of consciousness.
The right side of the screen is where you will find the
options to use when you are documenting. In this
case, the background is the color yellow and the
words “Select all that apply” are seen in the left
heading. With this type of question you can choose
several answers rather than being limited to just one.
“Select all that apply” questions will always appear
with a yellow background like this one.
You can select a response by clicking on the desired
selection. When you click on the choice an “x” will
appear inside the parentheses and the background
will change color. This patient is awake, so we will
document that now.
Here we can see the “x” filled in to the left of the word Awake.
If you accidentally select the wrong response, you can
unselect an answer by clicking once again on the chosen
answer and the “x” will disappear.
We will now finish our Neuro assessment by documenting
that our patient is Awake, Alert, Appropriate, and Follows
Commands. He is also arousable to Name and is oriented to
Person, Place, Time, and Event.
The next section asks you to describe the patient’s strength.
This question has a white background which means we can
only choose one selection / answer for this field.
There are certain questions in Meditech PCS that require
you to define a site to base your documentation on. These
are called occurrences. You can have more than one
occurrence for a certain question. When you select a site, all
of the documentation that follows will refer back to that site.
You will know you are documenting an occurrence because it
will have a small black arrow to the left of where the site is
defined.
Let’s assume that our patient is weaker on one side than the
other. If we were documenting that our patient had equal
strength, we could choose one of the bilateral selections.
Since we are documenting unequal strength, we will
document one side at a time. Let’s start by clicking on Left
Arm.
Now that we have documented Left Arm, all answers that
follow will pertain to the strength of the Left Arm. For the
Strength question, we will document that our patient’s Left
Arm has normal strength.
The next questions asks if this is baseline for the patient. It is
very important to make note of the patient’s baseline when
there is a deficiency so that those who follow you will know
that the deficiency was present before admission. Normal
strength is baseline for this patient, so we will answer this
question accordingly.
Now that we have documented the patient’s left arm strength,
how will we document the right arm? The same is true for
entering two different blood pressures, or pedal pulses, or two
different IV lines. Whenever you need to document an event
in more than one location, you need to insert another
occurrence.
Because you never can predict how many occurrences will be
needed to document, you are the one responsible for adding
additional occurrences. You will always be given the first
occurrence, and can add more when they are needed.
To add a new occurrence to document our patient’s right arm
strength, we have to make sure one of the answers for the
strength question is highlighted (as we see here for the
Baseline for Patient question). This will let Meditech know we
wish to add another occurrence for that section. All we have
to do next is click on the Insert Occurrence button at the
bottom of the screen.
We can see a second strength occurrence has been added to
our assessment. This is where we will now document the
strength of the patient’s right arm. We will now document the
patient’s right arm has mild weakness and that this is not
baseline for the patient.
It is often helpful to add a descriptive comment to explain
simple yes or no answer. Meditech will offer comment fields
whenever they are needed. To add a comment, you can type
it in the comment field for the question.
You have documented the strength for the patient’s right and
left arm. Now let’s document on our patient’s lower
extremities. We must add a third occurrence to do that. We
will now click on Insert Occurrence to add a third place to
document strength to this assessment.
The third strength occurrence has been added. The patient
has equal strength in both legs, so let’s document that now.
We will select Bilateral lower extremity, Normal Strength, and
Baseline – Yes for this occurrence.
We are now down to the question about Sensation. Our
patient does not have any sensation deficits, so we will select
No to that question now.
You will notice that when we documented No for sensation
deficit, the blue highlighted area of the screen skipped down
to the Comprehension Ability question. This is Meditech’s way
of letting you know it is okay to skip a certain piece of
documentation.
We have answered the remaining assessment questions to
complete this flowsheet. To move to the next body system in
the Med/Surg System Flowsheet, we will click on the Go To
button at the bottom of the screen.
The Go To window will open again. Here we can see the word
Neurological is a magenta color. This means at least one
question in that assessment has been documented. Now we
will move to the HEENT section of our assessment by clicking
on it.
This is the Head, Eyes, Ears, Nose, and Throat (HEENT)
assessment. This patient does not have any head, neck, or
face deficits, so we will answer No to the first question.
As you can see on the screen – now that we have
documented No for the first question about Head, Neck, and
Face deficits, the system has skipped us down to the Eye
documentation section.
Our patient has tearing and itching in both eyes. We will
document this information now.
Now we will look at the Eye assistive device question. Our
patient does not have glasses so we would document a No
for this question. If the patient does wear glasses, but is not
wearing them now, we could type that information in the
comment area.
The next several questions are marked Neuro patient only.
This means it is not necessary for you to document on pupil
characteristics for a patient who is not being evaluated for a
neurological diagnosis.
The rest of the questions on the HEENT assessment have
been filled in for you. We will now click on the Go To button to
select another piece of the assessment to document.
The first two pieces to our assessment have been
documented on, as evidence by the magenta color. Now we
will move on the the cardiovascular documentation from the
flowsheet.
This is the cardiovascular flowsheet. We will begin with
documenting our patient’s pulse, which is the subject of the
first group of questions on the assessment.
The first thing we must do is document where we took the
patient’s pulse. If you assess more than one pulse in separate
locations, you can add occurrences to record them. We took
an apical pulse on our patient. Since we are entering apical, it
is only necessary to choose a location – not a modifier – as
the word apical defines a location without needing to define
left, right, or bilateral.
We will now see how to use a new type of entry – a number
field. To document a number, we will click anywhere in the
pink and green rate box. Let’s see what this looks like.
A keypad will then appear for us to enter in our heart rate. At
the top pf the keypad is a normal range indicator. If our
patient’s pulse is between 60-100, the value will appear in the
green section of the rate box. If the pulse is low, it will display
in the pink section on the left; if high it will display in the pink
section on the right.
At the bottom of the keypad is the input range, which will vary
according to the type of data you are entering. The purpose
of this range is to help you guard against typing errors. If you
attempt to enter a value outside of this range, you will receive
an “Out of Range” message – as seen below.
To erase values you have typed on the keypad, you can use
one of the delete keys, highlighted here.
We now want to enter in a pulse of 90 for our patient. After
you click on the numbers on the keypad and the correct value
is displayed in the white box at the top of the keypad, we will
click on the Enter button in the top, right corner of the keypad.
This will close the keypad and deposit the value into the pink
and green box on the screen. Since 90 is within the normal
range, it displays in the middle green section of the box.
We have documented the remaining questions on the screen
and are ready to move onto he next section of our
assessment. We will now click on the Go To button.
We will pretend now that we already documented the
respiratory assessment (once again indicated by magenta on
our screen). We will move onto the Gastrointestinal
assessment now.
Our patient has no complaints of GI problems, so we will
answer no to this question now.
Once again, we will see our highlighted blue area skip down
to the bowel sounds section of the assessment, letting us
know it is okay to skip the 5 questions about GI symptoms.
We have filled out several more answers for you. Let’s take a
look at the Date of Last Bowel Movement Question. To
document this date, we would need to click anywhere in the
entry box, shown below.
This will open a calendar with the current date highlighted in
blue. The calendar is interactive. You can change the date,
month, or year by clicking on various places on the calendar.
Our patient reports his last BM was yesterday, so we have
clicked on that date on our calendar. Now we will click on the
OK button on our calendar keypad.
The rest of the questions on this piece of the assessment do
not apply to our patient, so we will move to the next piece of
our Med/Surg system flowsheet by clicking on Go To.
As we look down our list of remaining assessments, you will
notice that there is a female Reproductive and a Male
reproductive assessment,. You will only complete the one that
is appropriate for your patient, as we have done for you here.
All of the pieces of our Med/Surg system flowsheet have been
documented. Once you have reached this point, we need to
file (or save) our documentation. To be able to do this, we
need to get back to our Intervention List by clicking on Return
in the upper right hand corner of this screen.
When we return back to our Intervention worklist, we see an
extra line with purple text underneath our Intervention name.
It will show us the date and time our Intervention will be
recorded as being documented in the EMR/Chart.
To save our documentation, we must click on the File button
in the upper right hand corner.
Our Intervention worklist is now up to date and the History
column will reflect the time that our assessment was
completed.
The next admission document you will enter is the Past
Medical History. Our patient is an adult, so we will use the
adult version, but each unit has a similar assessment used in
the admission process. The Past Medical History is another
Group assessment.
To begin documenting, we must first highlight the selection we
want to document. We will click on the adult past medical
history now to highlight it.
With our Intervention highlighted we are ready to document.
We must click on the word document at the bottom of the
screen to begin.
The familiar date/time keypad will open, allowing us to back
time our documentation if we want. We are within the one
hour documentation time frame, so we will just click on the
OK button here.
Because this is a group assessment, our Go To list will open
on our screen with documenting options for each body
system. We will start by looking at the first one on the list –
Home Medications.
It is VERY important that we enter the Home Medications
correctly for our patient. The medications we enter here will
be used to print out a report for doctors/nurses to use during
the Medication Reconciliation process. Entering the
medications on this screen is the first step of the home
medication reconciliation process.
We must type exactly what the patient tells us and NOT “See
patient’s list of medications.” Pharmacy staff will also be
reviewing this list for possible drug interactions, etc.
There are specific instructions on this screen for us to follow.
The first instruction is found on the very top line in capital
letters – ENTER ONE MED PER LINE. We will do this by
typing a medication, then pressing the ENTER key on our
keyboard. Do not use commas or semi-colons to separate
meds. Each med must be on its own line.
This screen also tells us to enter ALL medications the patient
is taking at home, including Over the Counter (OTC) meds,
prescriptions, vitamins, herbal medicines, and any ear, eye,
or nose drops. We may need to ask the patient specific
questions to jog their memory about things that are not
prescriptions, as many people would not consider vitamins or
herbal remedies to be medications.
We are also instructed to include the name, dose, frequency,
and reason for taking the medication. In addition to this
information, we also want to include the last date/time this
medication was taken at home, to help care providers know
when it will be due next while the patient is in the hospital.
We will type in the medications one per line in the large blank
area highlighted above. Let’s see how it would look after we
correctly typed in some medications for our patient.
Here we see 3 documented medications for our patient in the
correct format. We now need to fill out the rest of the
Intervention. We will document that our source of medication
information is the patient and his family, and that he has left
his medications at home.
Sometimes a patient will not know the names of the
medications he/she is taking. We will still type exactly what
the patient tells us in the Home Meds text box. We must then
try to obtain the exact medication information from the
patient’s family, regular pharmacy, or from the patient’s
primary care physician, if possible.
If the patient is not taking any medications at home, make
sure to type that in the Home Meds text box. We never want
to leave the home med text box blank.
To move to the next piece of the Past Medical History, we will
click on the Go to button at the bottom of the screen.
Now we will click on the next section of the Past Medical
History – Cardiac.
Each of the past medical history assessments will first ask if
the patient has any history associated with the subject of the
assessment. If the patient does not, then no further questions
need to be answered on that screen. In the past medical
history, only the positives (or Yes answers) are documented.
Our patient has no history of cardiac problems, so we will
answer this first question with a No.
As soon as we answered No, the system knew no more
entries were required on this page, and automatically prompts
us to move to the next one. We will click on the Yes button
now.
We have been advanced to the Respiratory section of the
past Medical History for our patient. We see a similar
question at the top of the screen, allowing us to skip the
assessment if the patient has no applicable history. Our
patient has a history of asthma, so we will note that here.
Here we have documented our patient's asthma, and entered
a comment to provide more information about our patient’s
condition.
The rest of the respiratory history assessment lists respiratory
diseases you can answer Yes for, if appropriate. If the patient
has a history of a respiratory condition that is not on this list,
you can enter it in to the Other respiratory disorders section
at the bottom of this screen.
We are finished documenting our patient’s past medical
history for now. We will now click on Go to.
For a typical admission, we would walk through the rest of
these sections of the Past Medical History with the patient,
but since you already know how to fill in these simple Yes/No
assessments, we will pretend we have finished this
documentation.
Once all of our assessments have been documented, we will
need to save, or File them. To do that, we must close the Go
to window in the middle of the screen and click on Return in
the upper right hand corner to get back to our Intervention
List.
Now, a purple line of text will appear below the Adult Past
Medical History Intervention. This means the Intervention has
not been saved yet. To save what we have documented, we
will click on the File button.
One other thing it is important to mention is that if your patient
has been transferred to your unit from the Emergency Room,
the Past Medical History may already have been documented
by the nurse taking care of the patient in the ED.
If this is the case, there is no need to re-document the Past
Medical History for the patient. To see if the Past Medical
History has been completed in the ER, we can click in the
Assoc Data column for Past Medical History.
This will open up a window where we can view the
information that has been saved in the EMR/Chart for our
patient. We can view any text that is saved with the past
medical history by clicking on the name of the section with the
text bubble – in this case Hx Home Medications.
From this screen we can verify the information the ER nurse
documented with our patient. If the information is correct, we
can write a note stating that upon admission we reviewed the
Past Medical History that had been documented in the ER
with the patient, and the patient states the information is
correct.
If the patient provides you with additional PMH information
that has not been documented in the ER, you would go into
the Past Medical History Intervention, press recall values to
pull the previously documented information from the
EMR/Chart, and then add any new information for those
sections of the past medical history that need updating. You
will then File the changes.
When you are finished viewing the Assoc Data, You can click
on the X in the upper right hand corner of the Assoc Data
window to return to your Intervention Worklist.
The next Interventions we will document are the 4 sections of
the Admission Database. These Interventions are required to
be documented within 24 hours of admission. It is typically the
responsibility of the nurse who is admitting the patient to fill
these out.
We will start out looking at the Adult Database – General
Questions Intervention by double clicking on it. Double
clicking on an Intervention is another way of opening the
intervention documentation screen.
The General Questions Adult Database is different from the
interventions you have documented so far. It is a single
assessment instead of a group assessment comprised of
many pieces.
We have documented the date of arrival for you. Next, we will
document the time the patient was admitted to your unit. We
will click in the empty box to the right of the time question to
do this.
This opens up a time keypad for our documentation. Notice
the N button in the bottom right corner of this keypad. This N
stands for the word Now, and can be used if the patient has
just arrived to your unit. We will click on the N now to fill in the
current time for our patient.
Once we have used the keypad to fill in the arrival time, we
must then click on Enter.
We have filled in the next two answers for you. Let’s talk
about the Chief Complaint section. The Chief complaint is
what the patient says is the reason he/she is in the hospital. It
is not the physician’s diagnosis. We will enter in a chief
complaint for our patient now.
We have filled in the comment section of the screen with our
patient’s answer to our question of why they were admitted to
the hospital.
The next question is the onset of the chief complaint, or when
the patient began experiencing the problem. We have filled in
the date our patient began experiencing trouble breathing.
You are familiar with the remaining types of questions on this
screen, so we have filled in the remaining answer for you. We
will now file our assessment by clicking on the File button in
the upper right hand corner.
We are now back on our Intervention worklist and ready to
document another piece of the database. Typically, you would
document the clinical data section next, but for our lesson, we
are going to document the Adult Database –
Social/Environmental section next. We will double click on
this intervention now.
The first section of the screen refers to Physical and
Emotional Abuse. If you answer Yes to these questions,
notice the blue text on the right side of the screen that will
help you know what to do to follow up on the answers given
by your patient.
We have documented the Physical/Emotional Abuse section
for our patient. The next section deals with Tobacco Use. The
first 2 questions are required hospital documentation. Let’s
see what happens if we try to file now without answering the
smoking questions.
Meditech will give you an error message reminding us to
answer the required questions. We must document the
tobacco questions before we can file this piece of the
database. Required questions are fairly rare, and when we
are reminded to answer them it is because the information is
extremely important.
If we document that our patient uses tobacco or has smoked
in the past 12 months, hospital policy states that we must
provide Carenotes / smoking cessation education to the
patient. We can document that we have given our patient
Carenotes on the question of the database about Carenotes,
as highlighted on this screen.
We have documented the tobacco, alcohol, and drug use
sections for you. Also included in this section of the database
is Immunization documentation. This section contains 2
required fields. Pneumococcal vaccine and Influenza vaccine
documentation must be completed before filing.
We have now documented the remaining sections of this
screen for you. Now, we will click on File to save our
documentation.
We are back to our Intervention worklist. We have
documented the two remaining database sections for you, as
they do not contain any new techniques you need to learn.
The Intervention worklist is automatically updated each time
you return to it. It is also automatically refreshed every 10
minutes in order to show current documentation times and
information.
If you want to ensure the information on your screen is
current, you might choose to manually refresh your worklist
using the Refresh button. This is often useful when returning
to your worklist after putting in new physician orders for your
patient in Order Entry. You may have to refresh your worklist
to see the orders flow over onto your Intervention worklist so
you can begin documenting on them.
Keep in mind the worklist keeps current times from ALL the
people who are documenting on your patient, not just the
documentation you have performed.
Another piece of documentation that is required for all
admissions is the Skin Risk Assessment. We will double click
on this Intervention now.
This assessment is different from others we have seen
because it totals up our answers to provide us with a score.
Each selection you make will add points to the total score for
your patient.
We will now document some answers for our patient and see
what kind of score our patient receives.
Each of our questions has been added to give us a score of
11 for our patient. Because our patient scored below 12, he is
considered to be at high risk for developing a pressure ulcer.
At the bottom of the Skin Risk Assessment are Intervention
selections you can choose based on the patient’s score.
Choose the appropriate interventions for you patient based on
your patient’s skin risk score. We will select the Sof-Care
mattress for our patient from the high risk set of interventions
and then File our assessment.
Once you have completed all the admission Interventions that
have a frequency of “On Admission,” it is no loner necessary
to keep them on your worklist. If an intervention is not
finished, it is left on your worklist until it is completed.
We will now remove the Adult Past Medical History and the
four admission databases from your intervention worklist by
changing the status of these interventions to Complete. We
can change the status of several interventions at once.
To do this, we will first check off the interventions we want to
change by clicking in the blank column to the left of the
intervention name.
To change the status of these several interventions at once,
we will click on the edit status button at the bottom of the
screen, where an option will open on the screen for us to click
on the new status of complete.
The status column now has the letter
C in it for Complete, and has turned
green. The green indicator on our
screen reminds us we need to file our
changes. Let’s click on File now.
After filing the completed interventions, the worklist is much
shorter and more manageable. We can view our completed
documentation in the Open Chart/EMR. If we want to view
which interventions have been completed, we can use the
Select Status function.
When you click on Select Status, a menu will open on your
screen, allowing you to select which types of interventions
you wish to see on the screen. You can select as many
different statuses as you want by clicking on them. We will
click on Complete now.
Clicking on Complete placed a check mark beside it. Now we
will click on OK.
Now we are seeing both
the completed and active
interventions on our
worklist. We will now
change our view back to
showing only the
interventions with a status
of active by clicking on
Select Status again.
To remove the checkmark next to the Complete status, we will
click on it and then click on Enter.
We are finished this lesson on the Patient Admission Process.
Remember that in addition to what was taught in this lesson,
another responsibility of the admitting nurse (or unit
secretary) is entering the physician orders into the computer
system. There are separate lessons on how to enter orders.
The last thing we will do is exit all the way out of Meditech.
Let’s click on the Exit PCS button now.
Almost there! Let’s click on the red X in the upper right hand
corner to close the system entirely.
Great Job!
• You have successfully completed the
Initial Patient Encounter Tutorial
• Don’t forget to use the Meditech Help
Link on the Nursing web page of the
Infoweb to find extra tips and help.