Slide 1

Transcript Slide 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.MOH Location Find patient: Launch the Open Chart Select to suspend your session Enter your PIN – To re launch the session – If you need to reset your PIN – Please call the support center 5999

Meditech 6.0 Upgrade

Dietary

Session I

Acronyms

• • • PCS: Patient Care System – Intervention and Assessment Documentation – Notes EMR: Electronic Medical Record – Review patient information OM: Order Management – Review Orders

Agenda

• • • • PCS: Patient Care Systems – Overview – – Status Board Worklist – Care Planning – Documentation Functions OM: Order Management – Enter Orders – Clinical Data Screen EMR: Electronic Medical Record – Reviewing patient information ITS: Imaging and Therapeutic Services – Charge Entry

Registered Dietician Main Menu

• • List of Routines and Reports PCS Status Board will provide most nursing care routines

RD Main Menu

• • • • • PCS Status Board • Desktop – Patient Care Routines Patient Data Screen (Tech Desktop) Reconciliation Menu – Therapists Desktop – Charge Entry – Reconciliation Reports – Billing Reports Dietary – List of Dietary Reports Nutrition Custom Reports – List of Custom Dietary Reports

PCS: Patient Care Systems

Status Board

Patient Assignment List

Status Board/My List

Status Board Function Buttons • • • • 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 Patient Care Routines & Function Buttons

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

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 – My List • Launches your patient assignment list

Video Demonstration II

PCS Status Board

PCS Status Board

Exercise A: Find Patient by Location

1. Click [Lists] 2. Click [Find Patient by Inpatient Location] 3. Select [TEST.MOH Location] 4. Click [Assignments] - Right hand panel 5. Place a checkmark to the left of your TEST patient’s name 6. Click [Add to My List] -Footer Button 7. Click [Lists] - Right hand panel 8. Select [My List] 9. Confirm the patient has been added to your assignment list, then remove

Exercise B: Find Patient by Account

1. Click [Lists] 2. Click [Find Account] 3. Type Patient’s Name (Last Name, First Name) – Use your TEST patient • • • • 4. 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

Open Chart

• All Inclusive Patient Care Routine – Review Patient Data – – Complete Assessment Documentation Enter Orders

Open Chart

• • • • EMR Electronic Medical Record – Review Patient Data OM Order Management – Review Orders EMR PCS Patient Care System – Worklist • Intervention/Assessment Documentation – Write Note Clinical Data • View Allergies • View Home Medications • Enter/Review Patient information OM PCS

Open Chart: Patient Header

Location, Room, Bed Age, Sex DOB Height/Weight/BSA Medical Record Number Allergies Admit Status Account Number

Worklist

Worklist Worklist Functions • • • • Open Chart defaults to the worklist tab Documentation Routine – Interventions, Assessments, & Outcomes Worklist is shared by all Care Providers Care Items display based upon Care Provider Type – PT Assessments display for Physical Therapist – OT Assessment Display for Occupational Therapists – SLP Assessments Displays for Speech Language Pathologists Open Chart Routines

Adding a New Intervention

• • Interventions may be added to the worklist To add new intervention or set use the [Add] button

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

Add Intervention Routine

• • • Type the Intervention Name Select the Intervention And click save to add to the worklist

Exercise: Adding a New Intervention

1. Use your TEST patient 2. From the Worklist, click [add] 3. Select the [Any Word] tab 4. Type Nutrition 5. Hit [Enter] 6. Select the Nutrition and Follow Up Assessment 7. Click Save 8. Confirm that the Interventions displays on the worklist as expected

Worklist

• • • Interventions/Assessments will display on the worklist to be documented The worklist is clickable and sortable Click any of the worklist headers to sort the list

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

Documentation - Flowsheet

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

Documentation - Questionnaire

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

Video Demonstration IV

Documentation

Documentation

Exercise: Document Nutrition Assessment

1. Use your TEST patient 2. Start from the worklist 3. Place a checkmark in the now column for the Nutrition Assessment 4. Click [Document] – Confirm the time column displays the current date/time in the header – Review the documentation • Displaying from the last admission 5. Click [Mode] to toggle to Questionnaire Mode 6. Document and click save 7. Click [Save] 8. Confirm the last done column updates with the last time the intervention was documented

EMR Patient Care Panel

• Displays PCS Documentation – Assessments – – – Interventions Outcome Care Plan

Exercise: Reviewing Documentation - EMR

• • • • • • • • • • • Use your TEST patient Click [Patient Care Panel] Confirm that the [Assessment] Tab Defaults Select to view the Nutrition Assessment Place a Checkmark to the left of the Assessment Name Click [View History] Confirm that all documentation displays Click [Back] Click [Plan of Care] Tab – Header Click the [+] Symbol (in the description header) to Expand the Components of the Care Plan Review the Care Plan Components

Break

Documentation Functions

• • Temperature, Height and Weight Queries – Enable you to toggle between English and Metric Units within documentation Instance Type Queries – Enable multiple instances of documentation for various body locations or situations • IV Insertions, Orthostatic Vital Signs, etc

Documentation - Calculator

• • Enables you to toggle between English and Metric Units Regardless of the units of documentation, the display will default to English

Documentation – Instance Type

– – – – Enables multiple instances of documentation for various body locations, positions or situations • IV Insertions, Orthostatic Vital Signs Click the drop down arrow to invoke the group response Select the body location/situation Click Ok

Documentation – Instance Type

• • Document the fields for the situation/instance You may repeat the instance type documentation for the new body location

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

Documentation – Expand/Collapse

• Clicking the [-] symbol will collapse the field within the section

Documentation – Collapse

• • • • • Notice the temperature section is now collapsed You may now click the [+] symbol to expand Some sections will default as collapsed 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

• • • • • • • •

Exercise Part A: Documentation Functions Back Documenting

Use your TEST patient Select the [worklist] routine Select Nutrition Asssesment Click in the now column for Nutrition 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 Document Save

Exercise: Review Documentation in EMR

• • • • • Select [Patient Care Panel] in the EMR Place a checkmark to the left of the Nutrition Assessment Click View History Confirm that the Nutrition Assessment displays under the adjusted time (1 hour in the past) Click [Back]

Recall Values

Care Plan

Care Plan/Goals/Plan

• • Nutrition Goals and Nutrition Plan are documented within the Nutrition Assessment The Nutrition Goals section is an Instance Type – Multiple goals can be initiated and assessed

Dietary Goals Documentation

• • • • Free text the short term goals in the instance field – Liquid Diet Next you will document the time frame Also, you will document the progress The Rehab Goals Documentation will appear in the EMR

Exercise: Documenting Patient Goals and Rehab Treatment Plan

1. Document the Nutrition Assessment 2. Place a checkmark in the now column 3. Click Document 4. Click Mode to toggle to questionnaire mode 5. Scroll to the bottom of the assessment and find the Nutrition Goals 6. Indicate two nutrition goals 1. Click new short term goal to start an instance and free text the first goal 1. Document the assessment 7. Document the nutrition treatment plan

EMR Display: Nutrition Goals

• Nutrition Goals will be viewable in EMR – Clinical Panels

EMR Display: Nutrition Goals

• Dietary Goals will display in the Nutrition Summary Clinical Panel

Exercise: Review Goals and Plan in the EMR

1. Review the nutrition goals in the EMR 2. Refresh EMR 3. Click Clinical Panels 4. Select Nutrition Goals 5. Confirm the documentation from your Nutrition Assessment displays as expected

Worklist Management

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

Item Detail

Item Detail Column

• Item Detail Column – P: Protocol – – A: Associated Data I: Item Detail

Item Detail

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

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

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

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

Item Detail: Edit Text

• • Enter the text that you wish to display with the intervention Click save

Item Detail Text

The item detail will be viewable by clicking the “I” from the worklist or within the assessment

• •

Exercise J: Item Detail Text

Use your TEST patient For the nutrition intervention, write a note that the next care provider may need to know – Click in the item detail screen for the Nutrition Assessment – Click the [Detail] Tab – In the text field, click [edit] – Type a free text note – Click [Save] – Click [Back] to return to the worklist – Click the “I” in the item details screen to view the information – Click [Back] to return to the worklist – This is comparable to a post it note or Edit Text in MT Magic – Please note: The last documented text will print with the medical record

Video Demonstration VII

Item Detail/Editing & Undoing Documentation

Item Detail Edit and Undo

Exercise: Editing Documentation

1. From the Worklist, Select the last done field for the Nutrition Assessment 2. Select the last documented line item 3. Select the [Edit] button 4. Make an edit to your last documented assessment 5. Click [Save] 6. Note the new Edit Line Item 7. From the history tab, click the detail tab for the edit line 8. Review the “Old” Assessment and the “New” Assessment 9. The new (most accurate) assessment displays in the EMR

Change Status

• • If an intervention is added in error, you may change the status to remove or suppress the intervention from view Click in the status/due column and select to delete or complete the intervention

Undoing Documentation

1. From the Worklist, Select the last done field for the Nutrition Assessment 2. Select the last documented line item 3. Select the [Undo and Save] button 4. Select the Reason for Undo 5. Note the new Undo 6. From the history tab, click the detail tab for the edit line 7. Review the “Old” Assessment 8. This assessment has been stricken from the record and no longer displays in the EMR

Change View

• • The worklist displays active and discharge status items (only) by default To bring inactive entries to view click Change View

Change View

• • • This routine provides the ability to update the worklist display In this case, inactive interventions are selected to be added to the display.

Click Ok

Change View – Worklist Display

• • Note the Inactive Intervention now appears This intervention can be brought back to active status by selecting to edit the frequency

• •

Exercise: Intervention Status

Change the status of the Nutrition Assessment to Complete – Click in the Status/Due column – Select Complete – Confirm the Intervention no longer displays Bring the Nutrition Assessment back to active status – Click Change View – Select Complete from the Intervention status list – Click Ok – Find the Nutrition Assessment and click Complete – Change the status to Active

Notes Routine

• • • • • • Write Note provides the ability to enter free text notes Most Documentation is included within the Assessments Additional Information should be entered within the Assessment comments Notes should rarely be utilized – Reserved for unusual events that are not available within the assessments – Also utilized to generate Discharge Instructions and Page 2 Reports Be careful not to double document within the notes routine All Clinical Documentation is viewable from within the EMR

Notes Routine

• • To begin documenting click write note Next, select the note category (i.e. RD)

Write Note

• • You may choose to document a free text note Or, select Text to enter a canned text (pre populated note)

Canned Text

• • Upon selecting canned text, a list of available notes display Once the canned text is selected, the pre populated information will display within the write note screen. Canned text may be edited before saving .

Exercise: Notes Routine

• • • • • • • • • • Use your TEST patient Select Write Note Select Note Category: RD Select the Text Button From the list of Canned Text, Select Patient Off Unit Click F4 to navigate through and enter each of the free text fields Click Ok Click Refresh EMR Notice the Notes Button Turns Red Click to view the note within the EMR

•

Patient Reports

Standard Meditech Reports Pulled from the Status Board

•

Patient Reports

This will launch you to the reports routine You will define the report format and date and time to run the report

Examples of Patient Reports

• • Nutrition Assessment & Follow Up SLP Bedside Evaluations/MBS

Exercise: Patient Reports

1. Navigate to the status board 2. Click Patient Care Reports 3. Place a checkmark to the left of your patient’s name 4. Click Reports 5. Select the drop down arrow 6. Click next until you find the Nutrition Assessment & Follow Up Report 7. Select this report from the list 8. Select start date T-1 9. Click Ok 10. Select Ok to preview the report

Break

EMR Training

Agenda

• • • • • • • Introduction to the EMR Allergies, Code Status Non-Med Order and Order Set Entry Consults and Uncollected Specimens 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 Progress 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

• Electronic Medical Record (EMR)

Lunch Break

• • • • •

Exercise M: EMR

Use: MTPatient,TEST 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

Use MTPatient,Test What is the easiest and most succinct way to locate a patients standard of care and individualized plan of care?

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?

On the day of go live, where should you go to find all scripts reports?

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

• Entering Requisitions

Exercise S: Requisitions

• • Use the first TEST Patient on your Blue Card Enter the Requisition desktop and observe the different requisitions for the Quincy facility. Practice entering requisitions.

Suggested Orders – Nursing Documentation

• • • Some Nursing Documentation is set to trigger suggested orders/consults ie: Admission Assessment may trigger – Social Services Consult, Nutrition Consult, etc In this case, answering yes to the nutrition consult query will trigger a suggested order for a nutrition consult

Suggested Order

• • • The suggested orders screen displays Select the order and select Order Now or Undecided Remind again (if not appropriate) To proceed to Order Management, Click Ok

Suggested Order – Order Management

• • • The ordering provide and source will be selected Manager Order fields will be documented And, once the order is ready to be transmitted, click Submit

• •

Exercise T: Suggested Orders

Use the first TEST Patient on your Blue Card Document the Admission Assessment –

Typically, you would document all fields. For this example, document only the information indicated below:

– Primary Language: English – Chief Complaint: Chest Pain – – Information Provided by: Patient Patient Smoking Status: Never Smoked – Patient has an Advanced Directive and it is on file from prior visit – Patient has a Health Care Proxy and it is on file from prior visit – Patient has unintentionally lost 10 pounds in the last 6 months and a Nutrition consult should be ordered – Click Save – You are brought to the suggested orders screen

• • • • • • • • • • • • •

Exercise: Suggested Orders

Use the first TEST Patient on your Blue Card From the suggested orders screen, select Nutrition Consult and click Order Now Click Ok From Order Management, select the ordering provide and the order source Click [Ok] You are launched into Order Management Enter the required fields (indicated by an *) and any additional information Next, click Submit The order has been entered Navigate back to your status board – Click My List Next, Click the ACK prompt for your patient And, confirm the nutrition consult has been ordered Acknowledge the Nutrition Consult

Daily Documentation

M/S Hand Off Clinical Panel

• The Clinical Update Comments (documented within the Physical Assessments) will be viewable from the MS Hand Off Panel to assist with hand off communication

Patient Teaching

• • • Health Medication/Education – Teach Record Document all patient teaching from this Outcome This assessment is available for all disciplines

Outcome Documentation

• All outcomes are documented daily

Exercise U: Physical Assessments – Within Normal Limits

• • • • • • • • Use the first TEST Patient on your Blue Card Place a Checkmark next to Respiratory Assessment, Cardiovascular Assessment, and Genitourinary Assessment Document the Cardiovascular Assessment is within normal limits Document Genitourinary Assessment is within normal limits Document Crackles in the left upper lobe for the respiratory assessment Document the patient had boughts of apnea during lunch in the Clinical Updates Comment Save Review the documentation the M/S- Hand Off Panel

Exercise

• • • • Vital Signs – Document a set of vital signs Teaching – Document the Health Medication/Education – Teach Record • Document that you taught the patient’s wife about infection control precautions Intake and Output Assessment – Document intake for the shift: 100 mls – Urine Output: 50 mls from indwelling catheter Outcome Documentation – Place a checkmark next to each of the outcomes and document together – Document for each outcome that the patient is progressing toward the goal – And, for the Alteration in Health outcome, document a comment

• • • • • • • • • • •

Comprehensive Exercise

Use the SECOND TEST Patient on your Blue Card Find Patient by Account Add Patient to your List Add a new M/S/ICU Plan of Care Enter Patient Allergies and Height and Weight Document – Arrival to Unit/Admit or Transfer – Admission Assessment – – Past Medical History 6 Physical Assessments – Individualized Focus of Care Intervention Add 3 problems Add a new intervention: CPM Continuous Passive Motion Document Patient Teaching Document all outcomes Review all documentation in the Patient Care Panel of the EMR