Integrated Plan of Care: Medical Provider Education

 An integrated team approach that supports patient and family care  Use of MEDITECH® Patient Care System (PCS) electronic documentation More information: What is the Integrated Plan of Care?

On November 1 st  Adult inpatient area staff at ARH will begin electronic charting using Patient Care System (PCS)  New Thin Client computers and Smart Cards are available  FormImprint forms are changing What is Changing?

What is Staying the Same?  Physician orders and progress notes  Forms requiring patient or physician signature  Forms submitted to external bodies (e.g., Ministry of Health)  Medication Administration Record (MAR)  Printed monitoring material (e.g., ECG strips)  Nursing and allied health MICY and outpatient documentation

Navigating the Electronic Health Record in Meditech EMR

24 Hour View  Patient information can be viewed via the panels on the right hand side of the screen This is the initial view of EMR when opened

24 Hour View Displays Vital Signs, Intake and Output, Laboratory, and Reports performed in the last 24 hours

Vital Signs View Displays the Date/Time of Vital Signs & Vital Signs information

Graphing Click temperature Graph becomes active History of data selected  Vital Signs may be graphed to display trends over a period of time

Graph View

I & O – Intake and Output This displays the Intake and Output Totals and Balance

Notes  Displays clinical documentation by profession  Best for viewing assessments containing a lot of narrative writing, e.g., Social Work documentation

Notes Click the to display the full note Ensure “Assessments and Notes” is selected in the lower left corner Click to display specific content

Note Text

Care Trends It is organized by body system or specific topic (e.g., Cardiovascular data, Nutrition, etc.) Clicking the date/time stamp opens the assessment that these items are being pulled from This view displays specific data from clinical documentation in order to see trends

Care Activity This view displays all documentation including Assessments and Care Plans This view only expands the content of 3 Assessments at one time

Care Activity Right click up to 3 Assessments you want to display Click “Display” The Default view in Care Activity is “Assessments”

Care Planning  Interprofessional Care Plan can be viewed in the “Outcomes” section Outcome details can be viewed by clicking on the text box

 Provides a synopsis of the patient status specific to a topic Special Panels Cardiac Gastrointestinal Mobility and ADL Neurological and Behaviour Nutrition Pain Respiratory Urinary Wounds and Drains Mental Health Critical Care Informatics Hemodynamics Vascular Access and Infusions

Urinary Special Panel Example

Special Panels  Please Note: Special Panels provide a brief overview; for detailed information view the full assessment  Example: Pain Special Panel Displays information such as where the patient is experiencing pain, the pattern of pain, and pain score Click Pain Location to view complete pain assessment (e.g., quality of pain, radiating etc.)

How to Find...Where to Find...Recommended Views… Allied Health Documentation Care Activity  1. Assessments 2. Notes Care Activity: to view all documentation Note: to view all of one profession’s documentation and/or to view assessments with narrative documentation Care PlanCare Activity  Outcomes Care Activity  Outcomes: to view all outcomes from all professions Imaging Results & ReportsNo ChangeN/A Intake & OutputI&OI&O: to view all intake and output and totals for each Physician Documentation & Consults No ChangeN/A Finding Patient Documentation in EMR

Nursing Documentation Care Activity  1. Assessments 2. Care Trends 3. Notes Care Activity: to view all documentation; can be sorted by title, date or person who documented Care Trends: to view trending data (e.g. mobility, bowel movement type, etc.) Notes: to view any attached narrative notes Lab ReportsNo ChangeN/A Overview of key information Special PanelsSpecial Panels: Examples incudes Pain, Cardiac, Wounds & Drains Vital Signs Vital Signs: to trend and view all vital signs How to Find...Where to Find...Recommended Views… Finding Patient Documentation in EMR

Where can you find more information and resources

FH Pulse Meditech Physician Support