Transcript Clinical Transformation

Computerized Physician
Documentation
Emergency Department
September 2012
Objective
• To enter patient documentation
– Meditech (hospital, office, and home)
– Citrix (office and home use)
From the Tracker Board
#2
•
Step 1: Highlight the patient you want to document on
• Step 2: Click on DOCUMENT on right side of screen
If Previous Documentation
This screen appears once you click on
Document, showing all Physician
documentation on this patient
Click on Enter New for new documentation
List of Documentation
If you care to continue
Documentation already
started, click on the line
you are continuing.
You will be taken to the
report.
Then click Edit/Amend.
(red circle)
Mine vs. All
The Mine button
allows you to view
only those reports
documented by
you.
ALL will allow you
to see all reports
on this patient.
Click Mine to see
only yours.
Next Screen After ENTER NEW
Choose the desired
Template and double click
1
Initial Screen
2
Once template clicked
Blue Highlight bar appears
General Adult
SECTION LABELS
HPI
History of Present Illness
ROS
Review of Systems
PE
Physical Exam
MDM
Medical Decision Making
Depart
Discharge
Can only view one section
at a time.
Documenting
Nursing Documentation
will default in if RN has
completed assessments
(ex: reports CHF, reports
MI…)
Document
Click on item desired
Drop Down Box may appear
Area shaded in darker blue
relates to block on right
Use Search Box to start typing.
List will shorten based on letters
typed
Some fields will allow more than
one check, others only one.
Click OK/Next to go to next
component (line or query)
How to Document
– Once this information is complete, select OK/Next.
•
•
•
•
•
Will loop you to next item to document
May also go directly to another section by clicking on it
Some components have multiple choice selections
Choose by clicking on desired responses
To use all responses, document
abnormal first, then click
normal at top
• Any item with a * next to it
is a required field
How to Document
– Continue with OK/Next to go on to next screen until all
screens are completed
– For dates, T = today; T-1 = yesterday, etc.
– For times, N = Now (current time on computer)
• Times are in military time
– 8:00 am = 0800
– 8:00 pm = 2000
– Any comments may be made in the open area at the
bottom of the screen.
– To FILE:
• Click on Submit
• You will be asked for your fingerprint
Section Buttons
OK/Next: Inputs user’s
Information and goes to
next component, the one
below it
OK: inputs information,
does not go to the next
component
Cancel: cancels any
new information just put
into the component
Plus and Minus Signs
• A plus sign shows that
there is more detail if
you click and open
• A minus sign
compresses the topic –
can always be opened
again by clicking
Options
1
3
2
If click bubble at bottom,
can free text
When click OK, will
populate field
Comment Field
Comment:
Refers to space
highlighted in darker
blue on left.
When documented,
appears as a bubble.
Last bubble above
Comment allows free
text and adds in actual
space
Comments
1
Click button next to blank
And field will appear to fill in
2
Normal Button
1. Click on Normal
2. Click OK
3. Predetermined values
will automatically populate
the fields
1
3
1
System Normals
To get system normals,
double click header.
(HPI, ROS, PE, etc)
This screen will appear.
It allows you to default
normals for the systems
not affected at this visit
into your documentation.
Click Preview before using to
see normals
Typing Free Text
An open box (free text)
allows for charts
(such as these VS) to be
brought into the chart
V.S. from
Nursing
Documentation
An open box also
allows you to free
text items.
Navigate between the
Stop Codes to add
pertinent information.
[ ]
Next Stop (F2)
Next Stop takes you
to the next set of
Stop codes [ ] to allow
you to move through
a canned text
Functions of Free Text Screen
Data Formats
allows you to enter information from clinical review
Text
provides canned text
Next Stop (F2)
takes you in the free text space to the next field to fill in
OK/Next
keeps current data and goes automatically to the next query
OK
keeps data in field
Cancel
leaves field and takes data out
Add Section
provides detailed templates for more information
Normal
allows choice of inputting normal values
Quick Save
saves and allows you to resume next time you enter patient
Submit
files as permanent part of chart. CANNOT EDIT afterwards
Free Text Buttons
Buttons work
similarly to Word.
Free Text Buttons
listed above
Scroll Bars
Please look for
scroll bars that
denote there is
more to the screen
than is appearing
Hints to Charting
Click on any outliers first individually.
Then click on top of column that
Is left and the rest will default in
Example:
Clicked individually on:
Oriented x3
Facial droop
Speech slurred
Then clicked on N at top
for N – all bubbles left
completed with “N”
Add a Section
To add more detail based on chief complaint,
Click on Add Section and a list similar to the
one above will appear
Data Formats / Text
1
2
To add labs, etc.
(1) click on Data Formats
(2) then click on appropriate component
(3) allows data to be pulled in from elsewhere
Quick Save
Quick Save button
allows you to save
your data and come
back later to finish
without viewing
what you have charted.
It does not complete
your documentation.
To file as part of record, use
Submit.
Charting after Quick Save
When returning
after a Quick Save,
use Resume button.
You will return to
the original document.
To Sign
• Attendings to sign:
– Click Draft or Quick Save to come back later
– Click Submit and then Signed to complete
• Will be able to add addendum only
• Will not be able to edit once signed
• Residents/Medical Students to sign:
– Click Submit – Choose a Co-Signer
– Choose Draft
To File Documentation
•
Pending
–
•
Draft
–
–
•
Used by Residents
Can also be used to Save
Signed
–
•
Similar to Draft
Used by ED attending to finalize
Cancelled
–
•
•
Needs reason – reason is free text
Co-Signer – Is required for all Res/MS
– Choose attending provider name for this
patient
Required Data
–
–
•
Unable to sign before required fields
completed
Takes you directly to only those
components
Return
–
Takes you back to chart from where you left
off
Required Fields
Signed will not be
highlighted until all
required fields are
completed.
Once Required Fields are
complete, will be low-lit
and Signed will be
Highlighted.
Cancelled - Needs Reason
Reason
Notes
• If you would like to look at how the
documentation will appear in report form,
press F12 on keyboard
• Any item with a * is a Required Field
• If Sign is not lit, there are Required Fields that
need to be completed
– Choose Required Fields to finish needed items
To Complete after Patient Discharged
• From Physician Desktop choose PATIENT ROUTINES
• Choose Physician Documentation near bottom of list
• Type in patient’s name to choose correct patient 3
1
2
1
3
2
To Sign Documentation
Then use your fingerprint to sign documentation
Documentation is Complete!
ESigned
is Status needed
to have document
complete.
Other Statuses:
Temp
Draft
Pending
Cancelled
Don’t Forget to Sign !
From the Tracker Board if
Sign is Highlighted
ALL Orders/Documentation Have
Been Signed by You
Sign Button is Low-Lit
For Questions
The HELP Desk is available 24/7
Reach them at . . .
- or -
216-241-5115
15115 (in the hospital)
Resources:
Cathy Rhoades, Nursing IT Analyst
[email protected]
Diane McGregor, RN – Training & Support Facilitator
[email protected]