PCS/BMV Implementation RN PAT, SDC, PACU Session I 1

Acronyms PCS: Patient Care System Documentation Interventions

Agenda PCS: Patient Care Systems Overview Status Board Worklist Documentation Functions

Nursing Main Menu List of Routines and Reports PCS Status Board will provide most nursing care routines

Status Board

PCS Status Board Patient Assignment List Status Board Function Buttons Patient Care Routines & 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

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 Outpatient Location Provides a list of patients assigned to each location Provides the ability to add multiple patients to your list at one time Preferred method My List Launches your patient assignment list

Video Demonstration II PCS Status Board PCS Status Board

Exercise A: Find Patient by Location Click [Lists] Click [Find Patient by Outpatient Location] Select [SDC.DSMH (Day Surgery) Location] Click [Assignments] - Right hand panel Place a checkmark to the left of two patient names Click [Add to My List] -Footer Button Click [Lists] - Right hand panel Select [My List] Confirm that both patients have been added to your assignment list

Exercise B: Find Patient by Account Click [Lists] Click [Find Account] Type Patient’s Name (Last Name, First Name) Use the Patient Assigned to you by your Instructor Click to the select the patient account Select the Account Number with the REG SDC Registration Type The status Board will Appear Click [Add to My List] – Footer Button Select [My List] Confirm this new patient has been added to your List

Open Chart

Open Chart All Inclusive Nursing Care Routine Review Patient Data Complete Assessment, Outcome, and Medication Documentation Enter Orders Enter Allergies and Home Medications

Open Chart EMR Electronic Medical Record OM Order Entry Review Patient Data OM Order Entry Enter Orders PCS Patient Care System MAR Medication Administration Record Document Medications Worklist Intervention & Outcome Documentation Write Note Clinical Data Enter/Review Patient information EMR OM PCS

Worklist

Worklist Open Chart defaults to the worklist tab Documentation Routine Open Chart Routines Worklist Functions Open Chart defaults to the worklist tab Documentation Routine Interventions, Assessments, & Outcomes

Worklist: Standard of Care Upon registration a Standard of Care Automatically defaults Contains Standard Interventions most locations document Only document the Interventions which pertain to the Surgical Areas

Care Plan Process: New Admission Launch the Open Chart Use Patient Assigned to you by your instructor Confirm the Standard of Care Displays Add the Standard of Care: *PAT/Amb - Day Surgery Admit-Set Click Add Select the Standard of Care Tab Click *PAT/Amb – Day Surgery Admit-Set Click Save Confirm the following Interventions display Ambulatory/Day Surgery Adm Information Columbia Suicide Risk Rating Scale IV/Invasive*Line Assessment PACU Holding Area-Inpt/ED Preop Note PACU*Record Past Medical History Phase II/*Outpt Post Procedure Recovery Post Surgical Consult Review Pre-Adm Testing (PAT) Admission Info Pre-Surgical Documentation Reviewed Skin Assessment

Sort by Frequency Clicking the Frequency header will sort the list by frequencies

Documentation Overview

Documentation Overview Documentation mode defaults to flow sheet Provides a view of prior documentation Mode Button will toggle to Questionnaire mode Similar to a paper assessment

Documentation – Flow sheet Mode Current Date/Time Defaults Gray Background = View Mode White Column = Documentation Mode

Documentation - Questionnaire Clicking Mode will toggle to Questionnaire Style You may toggle between Questionnaire and Flow sheet mode at any time within documentation

Video Demonstration IV Documentation Documentation

Exercise D: Documenting PMH Start from the worklist Place a checkmark in the now column Click [Document] Confirm the time column displays the current date/time in the header Review the documentation Displaying from the last admission Click [Mode] to toggle to Questionnaire Mode Document PMH: Asthma, Diabetes- Insulin Dependant, Tuberculosis, Eczema, Epilepsy, Patient is not at risk for aspiration Any Body Systems with a Negative Response should be documented Click [Save] 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 E: Reviewing Documentation - EMR Click [Patient Care Panel] Confirm that the [Assessment] Tab Defaults Click the [Name] Tab – This simplifies the list of Assessments Select to view the Past Medical History Documentation 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

Documentation Functions

Documentation Functions Temperature Query Enables you to toggle between Fahrenheit and Centigrade Height and Weight Queries Allows users to toggle between Metric and English Instance Type Queries Documentation Functions Enable multiple instances of documentation for various body locations or situations IV Insertions, Orthostatic Vital Signs, etc

Documentation – Calculator Temperature Temperature Query Enables you to toggle between Fahrenheit and Centigrade Will always default to Fahrenheit

Documentation – Calculator for Height and Weight Enables you to toggle between English and Metric Units Regardless of the units of documentation, the display will default to Metric

Documentation – Instance Type Document the fields for the situation/instance Repeat the instance type documentation for the new body location In this case, BP and Pulse will be documented for Lying, Sitting, and Standing Positions

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 – Notice the Thermal Management Documentation defaults this way and can be expanded as needed 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 F Part A: Documentation Functions - Back Documenting Select the [worklist] routine Select Vital Signs Click in the now column for the Vital Signs 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 Next Step – Next Slide

Exercise G Part B Documentation Functions – Calculator & Instance Type Temperature: 98.6 Oral Pulse: 62 Orthostatic Vital Signs (Instance Type) Click “New Orthostatic Vital Signs” to start a new instance Lying Left Arm 120/80 Pulse 62 Click “New Orthostatic Vital Signs” to start a new instance Sitting 118/78 Pulse 63 Standing 115/70 Pulse 65 Click [Save]

Exercise H: Review Documentation in EMR Select [Patient Care Panel] in the EMR Place a checkmark to the left of the Vital Signs Assessment Click View History Confirm that the Vital Sign Assessment displays under the adjusted time (1 hour in the past) Click [Back] Click the [Vital Signs] Panel of the EMR and review the documentation

Recall Values

Recall Values Recall Values provides the ability to pull prior documentation to the current assessment To invoke the recall values function, click the [Recall] Button

Recall Values Recalls the entire assessment Recalls the section Recalls the individual query Assessment displays in green A column of diamonds appear to the right Select the diamonds to recall individual queries, entire sections, or the whole assessment It is critical that you review the recalled information to ensure accuracy before saving Recalling & saving = Signing your name to the documentation

Exercise I: Recall Values Document Past Medical History Click in the now column to select the intervention Click Document Click Recall Notice the screen turns green and diamonds appear in the right hand column Click to recall one query: select to the right of the cardiovascular history Click to recall the section: select to the right of the cardiovascular past medical history Click to recall the entire assessment: select to the right of the Past Medical history Confirm the entire assessment has recalled Review all documentation to ensure accuracy Update the GI Past Medical History Query Click Save

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, Flow sheet, and Associated Data

Item Detail Tabs Detail History Flow sheet Associated data Info about Intervention Intervention text (Post it note) History Audit trail of changes made to the intervention Flow sheet Documentation View in Flow sheet 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

Video Demonstration VII Item Detail/Editing & Undoing Documentation Item Detail Edit and Undo

Exercise I: Item Detail/Editing Locate the Pain Intervention Click the “P” to invoke the Pain Protocol Review the Protocol Click [Back] to return to the worklist Find the Vital Signs Intervention Click in the [Item Detail] Column Select the [History] Tab Select the last instance of documentation Click [Edit] Document that the patient is on room air and O2 Sat is 98% Click [Save] Confirm a new Edit Line Item displays Click in the detail column for the edit line item to review the old and new results

Exercise J: Item Detail Text For the vital signs intervention, indicate that the blood pressure must be taken on the left arm Click in the item detail screen for the Vital Signs Intervention Click the [Detail] Tab In the text field, click [edit] Type: Patient’s blood pressure must be taken on the left arm Click [Save] Click [Back] to return to the worklist Click the “I” in the item details screen to view the information Please note: The last documented text will print with the medical record

Editing Worklist Frequencies To edit a frequency, click on the frequency field This will invoke a drop down menu In the free text field type a “period” and enter a free text frequency (ie: .Q4H)

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

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

Adding a New Intervention Most Interventions are added to the worklist through the plan of care Additional Interventions may be added as needed To add new interventions 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 name of the intervention and click enter Select the Intervention from the List and click save

Exercise L: Adding a New Intervention Patient’s primary language is Spanish and she prefers to discuss health related issues in this language. You will need to utilize the Telephonic/Video Interpretation device to communicate with your patient and her family. Add the telephonic/video interpretation device intervention. From the Intervention worklist, click [Add] Type “Interpret” and hit [Enter] – Notice the intervention does not appear Click [Any word] – Notice the Telephonic/Video Interpretation Assessment appears Click the Intervention to select Click [Save] Confirm the Telephonic/Video Interpretation Assessment has been added to the worklist

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 V: Notes Routine Select Write Note Select Note Category: Nurse Select the Text Button From the list of Canned Text, Downtime Note 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 Care Reports Group of Meditech standard reports Available directly from PCS Status Board You may print Patient Care Reports for an individual patient or a entire patient location Examples: Nursing Kardex Care Summary Report Active Orders Report

Patient Care Reports Click Patient Reports Place a checkmark next to the patient’s name that you wish to print the report Print for a location Navigate to find patient by outpatient location Clicking in the checkmark header to select all patients

Reports Routine From the Patient Report Format Prompt, perform a look up to invoke the list of available reports

Patient Reports List You will be provided with a list of reports to choose from Select the report you wish to print

Patient Reports Click ok to print the report

Exercise: Patient Reports From the status board click the patient notes routine, click the reports button Place a checkmark to the left of your patient’s name Click Reports Select the Drop down arrow Locate and Select the Vital Signs-Last 3 Days Click Ok And, select preview from the print/preview screen

PAT Workflow Process PCS Status Board Lists Find Patient by Outpatient Location: Day Surgery Reg SDC account Open Chart Go to the Summary panel Enter Allergies Enter Home Medication list Enter Last Taken Information Click on Worklist Click on Add in the footer Click on Standards of Care at the top of the screen Choose PAT/Amb Day Surgery set Save On the Worklist check off the following assessments: Height and Weight Assessment Past Medical History Patient Rights for Care Decisions Pre-Adm Testing (PAT) Admission Info Vital Signs

SDC Workflow Process Click on Worklist and document the following assessments: Ambulatory/Day Surgery Adm Information assessment Pre-Surgical Documentation Reviewed IV/Invasive Line assessment to document the IV insertion I&O Intake and Output assessment Vital Signs

PACU Workflow Process From PCS Status Board: PCS Status Board Lists Find Patient by Outpatient Location: Day Surgery SDC account or Inpatient account if patient was already an inpatient before going to surgery Open patient chart Click on Worklist and document on: PACU Holding Area-Inpt/ED Preop Note: for holding patients pre-op PACU Record IV /Invasive Line assessment I&O Intake and Output assessment Vital Signs Any other assessment needed for patient If a patient comes to the PACU “holding area” from the ED or from the inpatient units: Document the following assessment:

For Outpatients going home from either PACU or SDC Document the following assessment: Phase II/Outpt Post Procedure Recovery assessment