Transcript Document Editing - Greater Baltimore Medical Center

Document Editing
PCS Lesson 4
Objectives
• List situations that require you to edit and undo
documentation
• Demonstrate how to edit your documentation
• Demonstrate how to undo documentation you
have mistakenly entered on the wrong patient
• Demonstrate how to document an intervention
that was performed in the past
• Learn how to return to incomplete documentation
and finish
In a perfect world, you would always document as soon as you
provided your cares and you would never make any mistakes. All of
your documentation would be completed according to schedule, and
you would never forget to answer a question.
Despite being careful about our documentation, inevitably you will
make mistakes or forget to document information that needs to be a
part of the patient’s record.
This lesson will teach you how to correct mistakes, how to undo
documentation that was mistakenly entered on the wrong patient,
how to retrospectively document, and how to complete interventions
you did not get a chance to finish yet.
All of our editing, back-timing, and undoing is possible to accomplish
from our Intervention worklist for our patient. Right now, we are
viewing our patient list, or status board. The patient whose
documentation we wish to edit has been highlighted. To access our
intervention worklist for our patient, we will now click on the
Interventions button on the right side of the screen.
We are now on our intervention worklist. We will first look at how to
undo documentation we have entered in error on our patient.
Whenever we wish to undo documentation of an entire intervention,
we will click in the History column for that intervention.
Let’s say we want to undo a height and weight we had documented
earlier because we had accidentally entered it on the wrong patient.
We will first click in the history column for this intervention.
This will open up a screen that displays all of the past episodes of
documentation for the height/weight intervention. The most recent
documentation episodes will be listed at the top of the screen. You
will look for your name in the Done by column, and then find the
correct episode of documentation you wish to undo by looking in the
Date/Time Done columns.
Now that we have identified which episode of documentation we
wish to undo, we will click on the intervention. This will highlight the
row green, as seen on our screen now.
Once the row is highlighted, all we have to do is click on the Undo
button located at the bottom of our screen. Let’s see what happens
when we click on Undo.
After clicking on Undo, we must select a reason why we are undoing the
documentation. Here, we have selected Incorrect Time. Now, we will click on
OK.
Now we see an extra row added to our screen. Notice the word
Undo with a green background in the Type column.
Note that the original episode of documentation still appears, just
below the episode where we have undone our intervention, as seen
highlighted here.
We cannot save what we have done from this screen. In order to
save our actions, we must return to the intervention worklist by
clicking on the Return button in the bottom right corner of our
screen. Let’s do that now.
This has brought us back to our intervention worklist. Notice the new
line of purple text underneath our height and weight intervention.
This is our reminder that we still need to file our actions. Let’s click
on Save now.
Now that we have clicked on save, our previous height/weight
documentation has been undone and will not be viewable in the
EMR/Chart for our patient.
Sometimes we may wish to edit what we have documented instead
of undoing the entire episode of documentation. The edit process is
similar to the undo process. Let’s see how we can edit our
documentation.
We realize we made a typing error when we entered in the
temperature for our patient in the last vital signs documentation.
Once again, we will use the History column to access the list of our
previous documentation. Let’s click in the history column now for
vital signs.
We are now on the documentation detail screen for the vital signs
intervention. Let’s locate the episode of documentation we wish to
edit. The temperature mistake was entered in our vital signs
documentation at 0418.
To change the temperature, we must double click on the row that
represents the time when the error occurred. We will double click on
the documentation row for 0418 now.
This opened up a screen that contains our entire 0418 vital signs
documentation for our patient. Changing values is easy. All you have
to do is click on the answers you wish to change and Meditech will
allow you to correct them right on the screen. We will now click on
the pink/green box to change our temperature.
Just like when you documented vital signs originally, the temperature
keypad will open on the screen. We will use the back arrow symbol
on the keypad to erase our previous documentation.
Our previous value has been erased and now we will type in the
correct temperature value using the keypad buttons.
We will now click the OK button on the keypad to deposit our new
temperature into our previous vital signs documentation.
We can now see the changes to the temperature displayed with the
rest of our previous vital signs documentation. We have no more
changes to make on this screen. We will click on the Return button
in the bottom right hand corner to get back to the edit screen.
Notice that just like when you Undo documentation, a new row
appears on our edit screen. This time, the word Edit appears in the
Type column with a green background.
Note that the original episode of documentation still appears, just
below the episode of editing, as seen highlighted here.
Same as before, we must click on the Return button to get back to
our intervention worklist, where we will be able to save our changes.
Back on our intervention worklist, we see a row of purple text
showing our name with the date, time, and the word edit, reminding
us we still need to file the edited information. Let’s click on Save
now.
Now that we have saved our changes, only the correct
documentation will appear in the EMR/Chart. It is important to note
that even through we won’t be able to see the previous temperature
documentation in the EMR, Meditech will still have a record of you
changing the temperature.
Meditech will allow you to make changes to your documentation for
3 days, even after the patient is discharged. Remember you should
only be editing your own documentation – NOT someone else’s.
Now let’s discuss how we can complete interventions that we have
started documenting on but haven’t finished. Sometimes you will not
be able to complete an entire assessment at one sitting without
interruption.
If you were documenting on paper, you would put the documentation
aside, perform your other duties, than return to the same paper
assessment to complete the documentation you had started earlier.
The same process is true when you are documenting on the
computer. If you Save an assessment in an unfinished state, you
can go back to it later to enter the rest of the documentation. Let’s
see how that would work.
Earlier, we began documenting on the personal hygiene
assessment. Half way through, one of our other patients needed our
help. We filed what we had completed documenting and logged out
of Meditech. Now we are ready to finish the documentation.
First, we will click in the History column of our personal hygiene
assessment.
Next we find the correct episode of documentation that we
started earlier, and double click on the row.
This will open up what we finished documenting before. We will pick up
where we left off and complete the rest of the intervention.
Our documentation is finished. Now we will click
on the Return button.
A new row appears on our documentation screen. The word Edit
appears in the green area of the Type column. We will click on
Return to get back to our Intervention List.
To save our completed documentation, we have to click on Save.
We will now discuss two ways we can retrospectively document
(or back-time) interventions.
It is important to remember to back-time your documentation in
Meditech if it is greater than one hour later than the time you
actually provided the care. For example, if you collect a set of vital
signs on a patient at 0700, you have until 0800 to enter them into
the computer. If it is past 0800, you must record the time you
actually documented the vital signs correctly in Meditech, so that it
doesn’t look like your documentation was completed later than the
scheduled time.
The easiest way to retrospectively documentation is by using the
Document button at the bottom of the Intervention worklist. Any time
you click on the Document button after clicking on an intervention to
select it, a date/time keypad will open, allowing you to change the
time.
Let’s see how we would do this. We want to record that we cleared
our patient’s dinner tray this evening at 1900. It is now past 2000,
and we have to make sure we document the time we actually
cleared the try correctly. We will start this process by clicking on the
Meal Intake Intervention on our screen.
Now that we have clicked on it, the Meal Intake Assessment is
highlighted green. Now we will click on the word Document at the
bottom of our screen.
This opens a date and time keypad. The time we enter on this
keypad will be the time the computer records that we actually carried
out the intervention. We will now change the time on this keypad to
1900 and the date to the day before – as it is after midnight now.
The time on our keypad is changed. We will now click on OK to open
the Meal Intake documentation screen.
Here is our Meal Intake Intervention. We have filled in the
documentation for you on this screen. Now we will Save the
documentation by clicking on Save in the bottom right hand corner.
Our Meal Intake Intervention has been saved. If you look in the
History column, the time is several hours past. This is because
Meditech saved the Meal Intake as being completed at 1900, not the
current time.
There is also an easy way to save several interventions completed
at a certain time, instead of one at a time. Let’s take a look at how
we can do that.
We want to record that we took our patient’s abdominal girth and
reapplied their SCDs at 0200 this morning. The first thing we will do
is click on the Document Stamp at the top of the Intervention
worklist. Right now the Document Stamp says Default Time,
meaning the current time. We want to change it to 0200. Let’s see
what happens when we click on the Document Stamp.
It opens our date/time keypad on the screen. First we will change
the time to 0200.
Now that we have changed the time, we will click on OK.
Notice that the Document Stamp at the top of the screen is now
showing 0200. Instead of saying Default Time, the document stamp
now says Fixed Time. All the interventions we document now – up
until the point where we save on this screen – will be saved as being
done at 0200. Let’s start by double clicking on the abdominal girth
Intervention.
We have documented this screen for you. We do not want to Save
yet because we still have to document the other intervention for
0200. To return to our intervention worklist, we will click on the
Return button.
Notice the line of purple text that is under the Abdominal Girth
Intervention. The time in the text is 0200. Let’s enter our second
intervention for 0200 now. We will not Save yet. We will double click
on SCD to open the intervention.
There is text added to the SCD Intervention. Before we can document our
SCDs, we must read the text. After reading the text, we will click on the OK
button. We will click on OK now.
We have filled in the SCD documentation for you. Once again, we
do not want to click on Save, we want to use the Return button to
take us back to the intervention worklist.
Now that we are back on our Intervention worklist, we see the purple
line of text added for the SCD documentation has the same time of
0200 listed. We are finished our documentation that we wanted to
record as being done at 0200. We can now click on Save.
Notice that now that we have Saved, the Document Stamp has
returned to the Default Time, which means it is back to the current
time. If we had Saved when we were in the intervention at the end of
our documenting, this clock would not have reset for us. This is why
it is so important to use the return button when documenting several
interventions for a past time and only save when you are back on
your Intervention worklist.
It is a good idea to pay close attention to your Document Stamp
when you are beginning to learn how to edit your documentation in
PCS. The time that shows in the document stamp represents the
time your documentation will be saved as being done in the the
computer.
Great Job!!
In this lesson, you have learned how to:
- Edit your documentation
- Undo documentation accidentally entered on the
wrong patient
- Complete documentation started previously
- Retrospectively document cares provided in the
past
* Remember if you need help, go to the Nursing
webpage on the Infoweb and click on the
Meditech Help Link.