Lesson Four: Accessing Demographics & Summary Information At the end of this lesson, you will be able to: Establish a Relationship with a patient Open a patient’s chart Identify the main tabs of the patient’s chart Access and identify the information available within the Patient Information tab

Establishing a Relationship When opening a patient’s chart, you will be prompted to indicate your clinical relationship as well as a reason for opening the selected patient’s chart. If your role only allows one type of relationship, the system will automatically assign your relationship and you will not be asked to do so.

Create A Visit Relationship Window Select the appropriate relationship by clicking on it to highlight your choice Tab to the comment field and enter the reason for accessing the selected patient’s chart. This is a free text, optional field. An Administrative Review relationship should be selected whenever you are opening a patient’s chart for reasons other than patient care. It is strongly recommended you indicated a reason in the comment field. Click OK, this assigns the relationship. Note: As long as your relationship remains active, you will not be prompted again for the selected patient.

Opening the Chart To open a patient’s chart from the Patient Search window: Highlight their name by clicking on it, and then click OK or Double click on their name It is important to carefully select the correct visit from the encounter section.

Patient Chart Tabs The tabs on the patient’s chart serve to organize the chart. Orders - Used to display patient orders and, depending on your clinical role, used to enter orders Inpatient Summary – Displays clinical data as staff contributes documented results to the patient’s EMR Nursing Handoff – Using by Inpatient Nursing staff for shift report. Displays patient documentation that was contributed to the chart. MAR Summary – Displays the patient’s medications in a view only mode Chart Summary - Pulls information from different areas of the chart into a single convenient view. Information such as the reason for the visit, allergies, diet orders, any isolation precautions and critical labs can be found here. Patient Information – Contains high level patient information. There are several subtabs within this tab Recent Results – Displays patient results Lab – Displays Lab results only Radiology – Displays Radiology results only

Patient Chart Tabs Patient Care Results - Displays results related to the patient’s care can be found here Summary Documents – Contains summary documents All Documents – Contains all documents such as transcribed reports, pathology reports, radiology reports, etc. Form Browser- Use Form Browser for a convenient way to view the complete details of any charting that has been done for a selected patient via forms. You are able to see the charted information in its entirety. Advanced Growth Chart – Allows you to view the patient’s growth chart information. This information is primarily contributed by the ambulatory sites during well child checks but can also be added by some inpatient clinicians based on the care of the patient. Immunizations - Allows you to view past immunization administration Task List – Displays task that are pending completion for the patient. Appointments – Displays past and current appointments for ambulatory sites.

Patient Chart Tabs Backward & Forward Buttons After accessing the different chart tabs the Backwards and Forwards buttons become available and will allow you to move through the tabs you previously accessed. The drop down arrow displays the locations previously accessed. By clicking on a tab you will be taken directly to that section. The Home icon takes you back to the first tab that you accessed.

Inpatient Summary Tab The Inpatient Summary view pulls information entered or viewed in different areas of the chart into a single convenient view

Inpatient Summary Tab Some of the documentation includes Patient Information, Vital Signs, New Order Entry, Diagnoses, Problems, Measurements and Weights, Intake and Output, Labs, Allergies Diagnosis, Home Meds, Isolation Precautions, Critical Labs and other information .

Let’s Discuss the Patient Information Tab Further The Patient Information Tab contains 3 sub-tabs. Let’s take a look at each one.

Patient Demographics Patient demographics displays information such as name, address, phone numbers, gender and date of birth. The Previous Name sections displays any aliases the patient may have had at CHKDHS.

Where Does This Information Come From? The information in the Demographics Tab is sent from Eclipsys or Epic to PowerChart. After a patient has been admitted or registered in Eclipsys or Epic, their demographic information will become available here. If the field is blank, the information may not have been entered in Eclipsys.

Visit List The Visit List Has a Split Screen The top contains information about all visits to CHKDHS such as Location and Admit and Discharge Dates and Reason for the Visit. The bottom contains visit specific information about the highlighted visit. Click on another visit to switch to that specific visit.

Patient Provider Relationship (PPR) Summary The PPR Summary will display all providers, by role, who have been involved in this patient’s treatment Separate lists are provided for lifetime and visit-specific relationships. Views can be customized to display all relationships or only current active relationships. The default view displays all relationships. Only Infection Control and Physicians can Establish a Lifetime Relationship.

Accessing Reports You can access reports, such as the “active order profile”, from within a patient’s chart. Click on the task button and then select “Reports”.

Accessing Reports Select the type of report you want and the date. Click “Print” to print the report. Leave the defaulted current date to get the most current information.

Lesson Four Review You learned how to establish a relationship with a patient. The system will establish your relationship if you can only have one role. Only Infection Control and physicians can have a Lifetime Relationship. You learned how to open a patient’s chart. You can identify the tabs of a patient’s chart. You can identify information contained in the sub-tabs of the Patient Information tab. You can access reports from the Task button.

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