PCS/BMV Implementation RN PAT, SDC, PACU Session II

Session II Agenda MAR/BMV Documentation Daily Documentation Patient Reports Medication Reconciliation Process & Home Medication Entry Vaccine Documentation Process Review Exercises Admission Inpatient Transfer/Hand Off Discharge Home Home with Services Transfer to SNF Additional Nursing Routines Bed Board Discharge Routine Downtime Go LIVE

eMAR/BMV General Info Acronyms – eMAR: Electronic Medication Administration Record – BMV: Bedside Medication Verification Scan Patient Scan Medication Verify 5 Rights of Med Administration Functions – View Scheduled Administrations – View Orders and Dose Instructions – Document Med Administration Expected Outcome – Reduction in Medication Administration Errors – Improved Completeness of Documentation – Improved Safety

MAR Overview/Acknowledge review

Explain

MAR Layout: Functions Refresh: Refresh new data manually Change View: Changes the view of data displaying on the MAR Document: Document an administration (manually-not using scanning) » Not Recommended! Document Unscheduled: Document an administration that is not scheduled Document Assess: Document an MAR assessment Detail: View the detail of the MAR Order Manual Barcode: Enter Medication Barcode Manually Renewal: Flags when certain medications are approaching their renewal date/time Med Review: Will not be utilized Schedule Comment: Enter a comment for a medication schedule

Medication Detail Panel Med Detail Info Tabs Detail – MAR Detail History – Audit Trail Flowsheet – Assessment Documentation Associated Data – Related Queries, Labs, etc Protocol/Taper – As Indicated Order Detail – Audit Includes Many Tabs of Order Information

Medication Detail: History Tab Order Information Audit Trail Line Items Audit Trail Detail

Medication Detail: Flowsheet Tab Flowsheet Documentation associated to the particular Medication

Medication Detail: Monograph Tab Medication Monograph Viewable Print-able English/Spanish Order Detail

Medication Detail Associated Data Tab Order Detail Associated Data Query Documentation Lab Results

Medication Detail: Protocol/Taper Tab Order Detail Associated Data Query Documentation Lab Results Protocol or Taper as Indicated

Order Detail Fluid Volume Info Titration Info & Protocol ACK Audit Trail

Medication Detail Panel Review Med Detail Info Tabs Detail – MAR Detail History – Audit Trail Flowsheet – Assessment Documentation Associated Data – Related Queries, Labs, etc Protocol/Taper – As Indicated Order Detail – Audit All of the info just covered, is viewable from the MAR Detail Tab

Acknowledging Orders

Two places to Acknowledge Med Orders MAR Ack Routine Status Board Ack Routine Acknowleding Orders from the Status Board will Auto - Ack on the MAR!

Status Board Acknowledgement Routine Preferred Method of Acknowledging Meds – Enables Acknowledging multiple meds at one time – Review Order Detail Screen in less clicks

Status Board Acknowledgement Routine 1.Click Each Order to review the order detail 2.Click Acknowledge 3.Save Order Detail

MAR Acknowledgement Routine Orders Acknowledged from the status board will be acknowledged on the MAR Acknowledged

MAR Acknowledgment Routine To Ack from the MAR you will review the medication cell as well as the order detail. 1. Highlight Med 2. Review the medication cell Five Rights 3. Click the detail tab to review the Order detail

MAR Acknowledgement Process Review all items of the medication detail screen

MAR Acknowledgement Process 1. Click on the red Unacknowledged status 2. Select Acknowledge Order

Reject Acknowledgement If a medication order is incorrect, reject the order Place a phone call to pharmacy Acknowledgement may be edited as needed

Acknowledging Medications Acknowledging is signing your name to the order Obtain/Review appropriate information before signing off On MAR – Review main MAR & Five Rights Right Patient Right Medication Right Route Right Dose Right Time – Click Detail Tab to review the Order Tab and Audit Trail Order Source Edits Made Status Board (ACK Routine) – All information on one screen – Five Rights – Order Audit

Warning: Never ACK Upon Admin Admin before ACK: “Medication has not be acknowledged” Click Cancel and Review Order Detail! Never select Acknowledge and Document – You will not be presented with enough info

Exercise: Acknowledge from the Status Board Use the patient from your scan sheet Click [Lists] Select [Find Account] Type Last Name, First Name Add the Patient to your My List From the status board click the ACK field Find the Furosemide Order Place a checkmark next to the Furosemide Review the Order Detail – Who entered the order? – What time was the order entered? Once you feel comfortable with the information click acknowledge Click Save Click Return to the Status Board Scan the Patient’s Wristband Enter your Pin Confirm that the Furosemide has been acknowledged on the MAR

BMV Scanning

BMV: Scanning Scanning the barcode will Automatically Locate the Medication on the eMAR Multiple Medications can be Scanned and Administered Before Saving Documentation Technique: – Position scanner near the barcode – Slowly move the scanner away from the barcode, and close again until beep is heard – View screen for confirmation If the Wrong Patient is Scanned, you will be alerted that the account number is incorrect You will not be able to scan medications until the patient’s wristband has been scanned

Exercise: Acknowledge Meds/Basic Admin Confirm the Header Displays “Verified” – This indicates you have scanned the wristband Scan the Lasix (Furosemide) Barcode – Confirm a barcode displays in the Medication Cell – Confirm the admin date/time and barcode displays in the admin time field Click Ok to Proceed to the Summary Screen From the Summary Screen review the admin information Click Save Confirm that the Administration Date/Time displays in black text, indicating the admin has saved to the MAR

Administration Documentation Process

Administration Process Review Scan Patient’s Wristband Scan Medication barcode Review & Update Med Administration screen Review Med Protocol Information Date/Time of Admin Dose Admin Comments Assessment Click Ok on the Admin Screen Click Ok on the MAR to proceed to summary screen Review summary screen for accuracy and click save when complete

MAR Admin Step 1: Scan Patient & Medication Scan Wristband Scan Medication

MAR Admin Step 2: Review/Document Admin Screen Review & Update the Admin Screen – Ordered dose and scanned dose – Schedule Date – Administered Dose in mg – This information can be edited as needed Once you have confirmed this documentation is accurate, click Ok

MAR Admin Step 3: Review MAR Once you click Ok from the admin screen, you are brought back to the MAR The Admin Date updates the Admin Cell in Green Text (Green = Pencil) – Admin has been documented but has not yet saved to the record You may scan multiple medications at one time Proceed to Summary Screen – Document another med admin – Proceed to the summary screen to review and save

MAR Admin Step 4: Review Summary Screen Med Admin Summary Screen Review Admin Documentation before saving Confirm documentation is correct – Click back to edit the administration – Click save to save this to the EMR

MAR Admin Step 5: Save the Administration Once the admin has been saved it will display in black text This confirms the administration has saved to the EMR

Administration Screen Details

MAR Administration Screen Once the Medication is scanned, you are launched into the Admin Screen Medication Administration Screen – Scan List – Admin List – Flowsheet – Protocol/Taper – Associated data – Monograph – Links Main MAR Order info Scan List

Medication Administration Screen MAR Order Information Scanning Detail Administration info – Scheduled Date – Administration Date/Time – Admin User – Administered dose – Non Admin Reason – Admin Comments Admin Date: Date med was given Edit to Back Document Dose: Amount of med given Edit to adjust the administered dose

Medication Administration Screen Flowsheet Tab – Order Info – Scanning Detail – Administration Assessment

Medication Administration Screen Drug Monograph Tab – Order Info – Scan Detail – Monograph

Medication Scenarios

Split Meds Dose Dispensed: 10 mg tab Dose Ordered: 15 mg Split one tab Administer 1.5 tabs

Split Medication Scanning the first tab will launch the administration screen Next, scan the second tab

Split Medication Now, the medication scanned is larger than the ordered dose Split the second tab And, edit the Administered dose to reflect the dose given to the patient Meditech restricts the ability to save a dose greater than what is ordered

Split Medication Now the ordered dose matches the scanned dose Once you have confirmed the information, click Ok

Exercise: Split Medications Document the Lisinopril Administration – Scan the patient’s wristband – Scan the first 10 mg tab of Lisinopril – Review the administration screen – Scan the second 10 mg tab of Lisinopril – Attempt to save Notice you are prevented from saving a dose greater than what is ordered – Split the Medication – Edit the Administered dose to 15 mg – Click Ok – From the MAR Click Ok to proceed to the summary screen – Review the information on the summary screen and click save

Bulk Meds Examples of Bulk items – Creams – Ointments – Inhalers – Eye drops – Insulin (without a scheduled dose such as sliding scale) The bulk items will require you to enter the number of….. Applications, puffs, drops, units, etc.

Bulk Medication Timoptic 5 % Opth Soln (Timolol) – Bulk Med – Dose Instructions Indicate Dose and Units – Dose and Units will be entered on the Admin Screen

Bulk Medication Indicate the Dose and Units for the first administration For Each Admin moving forward, the units will default

Bulk Medication Click Ok from Admin Screen Click Ok from MAR Click Save from Summary Screen

Exercise: Bulk Medications Document the Timolol Administration – Scan the patient’s wristband – Scan the Timolol – Review the administration screen – Document the Dose – Document the Units – Click Ok from the Admin Screen – From the MAR Click Ok to proceed to the summary screen – Review the information on the summary screen and click save

One Time Meds Once ONE = One time Med Medication will automatically discontinue once the administration is documented Discontinued Meds fall to the bottom of the MAR and display for 24 hours

One Time Medication Admin screen automatically launches the flowsheet/MAR Assessment IV Medications require that the injection location is documented Some Meds display Associated data – Reviewed prior to administration Click Ok From the MAR click Ok to proceed to the summary screen Save

One Time Medication Once the med is documented, it auto discontinues and falls to the bottom of the MAR Yellow = Discontinued Discontinued meds default to display for 24 hours Discontinued meds can be edited as needed

Multi Component Medications compounded in the pharmacy Each component will be scanned separately Verifies correct medications have been added Scanning the first barcode will launch the admin screen

Multi Component Med Notice the Cefazolin has been scanned Next, scan the Sodium Chloride

Multi Component Med Both Medications have been scanned Confirm the information is accurate Click Ok From the MAR Click Ok Then, click save from the summary screen

Exercise: Multi Component Medications Document the Cefazolin Administration – Scan the patient’s wristband – Scan the Cefazolin – Review the administration screen Confirm a barcode displays with the Cefazolin – Scan the Sodium Chloride – Click Ok from the Admin Screen – From the MAR Click Ok to proceed to the summary screen – Review the information on the summary screen and click save

Patches Patch administrations will be documented on the MAR Utilize MAR Assessment to document: – Location – Removal of previous patch – Application of New Patch

Exercise: Patch Admin Document Nicotine Patch Removal and Application – Scan Patient’s wristband – Scan Medication – Document that you are removing previous patch and applying a new patch to the left arm – Click Ok – From the MAR click Ok to proceed to summary screen – Save the administration from the summary screen

Overrides Med that is pulled prior to the order being entered Will show on eMAR as a.STK-MED ONE Displays the dose removed –NOT the dose ordered –Adjust the dose appropriately when administering One time order –Automatically discontinued once admin is documented –Next, MD will Enters the Order to justify the override –MD Order admin time will be reconciled –Documented as Non Administration/Administered on Override RX

Exercise: Override Med Scan patient Select the Pyxis override Morphine order (STK MED ONCE) – In an actual scenario, you will not see the second pharmacy order yet. Scan the Morphine Note that you removed Morphine 4 mg/ml via IM, but the order is to give Morphine 2 mg IV Click on the dose to adjust the dose to 2 mg. Now document the correct route on the assessment that appears; then Save Note the order turns yellow and drops to the bottom in a discontinued status Review the history to see the dose administered Once pharmacy processes the order, you will need to document on the new order a “Non Admin Reason” of “Administered on override RX”

Exercise: Override Step 2 – Reconciling MD Order The Second Order will be documented as a non administration – Remember: This Medication Administration was already documented on the Override RX – Scanning will not be required here Highlight the 2 nd Morphine order Click “Non Admin.” Choose Reason of “Administered on override RX.” Save

Renewal Reminder Certain medications will flag for renewal – IV Medications after 24 hours Reminder that the Medication is approaching it’s discontinue date/time – A message will display upon entering the MAR – The Renew button on the MAR will display in Red

Renewal Reminder The Renewal SCH/FREQ tab will flag in red if a medication is due for renewal

MAR Functions

MAR Functions Overview (Edit, Undo, Cosign)

Edit and Undo - Detail Tab Detail screen will provide the ability to edit and undo medication administration documentation

Medication Detail – History Tab Audit trail of changes made to the medication – Acknowledgement – Administration – Edit/Undo Activity Edit/Undo Functions Available

Edit Screen Select the fields you wish to edit

Edit Screen Here, the administration time is edited and a comment is documented

Edit – History Tab History displays a new edit line item with the old and new values Green = Pencil Click Save to Save the edited documentation to the EMR

Editing Medication Documentation Select Furosemide Click Detail Find the last documented adminstration Click Edit Change the time of administration Enter a new comment Click Ok Review the old and new value Click Save

Undo Medication Documentation History screen allows you to undo documentation

Undo Medication Documentation A new undo line item will display Green = Pencil Click Save to save the undo to the EMR

Undo Medication Documentation The administration time now displays as overdue It is important to reconcile all scheduled admin times

Non Administration If a medication will not be administered, this will be indicated with a non administration reason Click on the scheduled date/time and select not given

Non Administration Select a Non-Admin Reason Click Ok from the MAR to proceed to the summary screen Then Click Save

Exercise: Undo Click the Timolol Click the Detail Function Select the last documented administration Click Undo Select a Reason for Undo Click Save Confirm the Administration time appears on the MAR as overdue

Exercise: Non Administer Click the Timolol Overdue Scheduled Time Select Not Given Select a Reason Click Ok Review the Summary Screen Then click save

Edit/Undo – Via Admin Cell Edit & Undo Functions are available from the admin cell drop down menu Click the Admin Date and Time, and select the function as needed

Co-Signing Medications

Co Signing Medication Documentation Some Medications will require a co signature (High Risk Meds ie Insulin, Heparin) Co Signature is ONLY required when administering med (if med is not given, co signature is not required) Co Sign Requirement is indicated by the double pen symbol in the Medication Cell The co-signer should witness the admin – Co Signer Enters Name & Pin Click Ok

Exercise: Insulin & Co-Signature Navigate to the MAR Document Insulin Administration – Work in pairs and alternate witnessing the admin/co-signing – Scan the patient’s wristband – Scan the Insulin Barcode – Review associated data – Document MAR Assessment – Click Ok – Obtain Co - Signature – Save

Back Documentation In the (rare) and emergent event that you are unable to document a med admin at the time the medication is given, you may back document Scan the patient and Scan the med (if you saved the label) On the Admin Screen Change the Admin date to the date the med was given

Back Documentation Change the Admin Date You may also document an admin comment to explain why the medication was not documented at the time of administration

Pain Med: Pain Assessment/Re Assessment The pain assessment will be documented for all pain meds Scanning the med will launch you to the flowsheet to completed documentation Past Pain Assessment Documentation will display from – MAR Assessment – Intervention Worklist Documentation Assess the patient’s pain Once the assessment is saved, a re assessment will be triggered to be completed 60 minutes after the med administration time

Pain Med: Pain Assessment/Re Assessment Click Ok From the MAR click OK to Proceed to the summary screen Save the Med Administration

Pain Re Assessment The administration now displays with the accurate time the med was given Also, a pain assessment is now due

Status Board: Pain Re-Assessment Reminder Status board Next Med cell displays upcoming med times – Includes Re Assessment Reminders Acetaminophen 650 PO Q4H PRN: Indicates the Pain Re Assessment is due for the Rx Associated – Click Go To MAR to launch the MAR for this Patient

Pain Re Assessment To document the pain re assessment, click on the scheduled time and select to document.

Exercise: Back Documentation 1.Back document the tylenol – Scan the Patient’s Wristband – Scan the Medication Barcode – Document the Initial Pain Assessment – Click the Admin Screen – Change the Admin Time to one hour in the past – Document a comment to explain why you are back documenting – Click Ok – From the MAR, click ok to proceed to the summary screen – Review the summary screen – Click Save 2.Navigate to the Status Board 3.Click the Next Med Field for this patient – Confirm the Pain Re Assessment Is Due 4.Click [Go to MAR]

Exercise: Pain Re Assessment 1.Click the Status Board Button 2.Click in the Next Medication Due field 3.Notice the displays 4.Click Go to MAR 5.Enter your PIN 6.Document the Pain Re Assessment – Click on the scheduled time for the Line – Select Document – Document the Pain Assessment – Click Save

(PCA/Epidural) This MAR Assessment will be associated for PCA and Epidural Meds

PCA/Epidural Assessment Add PCA/Epidural Assessment to the worklist Document pain, settings and assessment of the effect

Exercise: PCA MAR Admin & Assessment Document the Morphine PCA Admin on the MAR Add the PCA/Epidural Assessment to the worklist – Save Document the PCA Assessment – Pain – Assessment – Settings – Save

Titrations Overview Titrations will be documented on the MAR This is indicated by the word TITRATE and the IV Pole Symbol Titrations are documented as unscheduled administrations

Titrations Scan Patient’s Wristband Scan Medication Barcode You will receive this message: – “No Scheduled Administrations Exist. Do an unscheduled administration instead?” – Click Yes

Titration – Administration Screen On the initial administration screen document the rate Based upon the order/protocol, enter the dose into your smart pump to calculate the initial rate Enter this rate into the Meditech admin screen Click Ok

Titration - Flowsheet Once you enter the rate, you will launch the admin screen – flowsheet tab Review the associated data information The rate will default into the flowsheet from your initial administration Next, document the dose Click Ok From the MAR, click ok to proceed to the summary screen Then, click save

Titration Your Flowsheet documentation will update the current dose field on the MAR

Documenting Dose Changes To launch the Titration flowsheet to document dose changes click the IV Pole symbol from the MAR

Titrations Slide Upon launching the flowsheet you will document the dose and rate Click insert column to document multiple columns of documentation for frequent rate changes

Clinical Panel: Titrations Displays pertinent clinical data with the titration data to be viewed and trended

Exercise: Titration Document Dopamine – Scan the Patient’s Wristband – Scan the Dopamine Barcode – You will be presented with a message: “No Scheduled Administrations Exist. Do an unscheduled administration instead?” – Click Yes – From the Initial Administration screen document the rate: 1 ml/hr – Click Ok – You will default to the Protocol Tab review this information – Then, click the flowsheet – Confirm the rate is correct – Document the dose – Click Ok – From the MAR click OK to proceed to the summary screen – Then click save – Confirm that the medication order cell has updated with the new rate

Additional MAR Scenarios: (Meds w/ same barcode, less than/more than ordered dose, manual admin)

Meds w/ same barcode If there are multiple meds with the same barcode you will be presented with the MAR Multi Match Screen From this screen you will select the order that you wish to administer against Examples – Active Order and Discontinued Order – Pyxis Override Order and Active MD Order

Less than ordered dose You are not prevented from saving an admin for a dose less than the ordered dose You will be flagged when saving the admin The Admin will display in red text indicating a dose less than ordered dose was administered

Exercise: Less than the Ordered Dose Document administration of Lisinopril 10 mg – Scan the Patient’s wristband – Scan the Lisinopril 10 mg tab – Notice you are under by 5 mg – Click Ok on the Admin Screen – Confirm that you are flagged that the admin is less than the ordered dose – Click Ok from the MAR – Click Save – Notice the administered dose displays in red text

More Than Ordered Dose You will be prevented from saving an administration for more than the ordered dose Upon clicking Ok, you will receive an error message and will not be able to save the admin

Exercise: More than the Ordered Dose Attempt to administer Lisinopril 20 mg – Scan the patient’s wristband – Scan the Lisinopril 10 mg tab – Confirm you have launched the admin screen – Scan the second Lisinopril 10 mg tab – Click Ok – Confirm that the admin screen prevents you from administering a dose more than what has been ordered

Manual Admin Manual barcode Function – Use if barcode is unable to be scanned – Type the barcode number manually Report barcode scanning issues to pharmacy

Exercise: Manual Barcode Document the Acetaminophen Administration – Scan the patient’s wristband – Click Manual Barcode to manually enter the Acetaminophen NDC Number – Type: – Click Ok – Complete the MAR Administration information – Click Ok to return to the MAR – Click OK to proceed to the summary screen – Review the summary screen and click save

Document If the medication barcode is not available you may use the document button to manually document This is the least favorable method, as it circumvents the barcode scanning safety feature

MAR management Change View, Overdue, Future, Reconciling before end of shift

Change View MAR Default View – Sort: Start Date/Time – Days of Discontinued Medications Display: 24 Hours – Days into the past to view the MAR: 5 days – Days into the future to view MAR: 1 day Change View provides the ability to change the MAR view

MAR Change View View Dates should be set to All – Next Due will suppress important information from view Save to preferences will save the settings permanently Clicking Ok will save the settings for this session only – Once the chart is closed, the default settings will be respected moving forward

Overdue and Future Overdue medications display in red text Future scheduled times display as a white cell Overdue Future Scheduled Dose

Exercise: MAR Management Click the scroll bar above the scheduled date and time to view one day into the future Click Change View Update “Days into the Future to View MAR” to 3 Days Click Ok Now click the scroll bar to view three days into the future

Reconciling MAR – Shift Hand Off It is important to review the MAR during hand off Any over due medications should be reconciled or communicated to the next shift The next nurse should not be left to reconcile an overdue med You are only able to document your own administrations Hand Off is the best time for overdue meds to be discussed and reconciled

Daily Documentation

IV Documentation Med Admin when hanging Bag – MAR IV Insertion: IV/Invasive Line Assessment - Worklist IV Assessment: IV/Invasive Line Assessment - Worklist Intake: Intake and Output Assessment - Worklist Remove of the IV Line: IV/Invasive Line Assessment - Worklist

IV Documentation: MAR Medication Administration Document the IV Med Administration on the MAR This verifies the five rights and indicates that bag is hanging

IV Documentation: IV Insertion – IV/Invasive Line Assessment Document the IV Insertion from the Worklist Utilize the IV/Invasive Line Assessment Select the appropriate instance (IV/Peripheral Access or Central Line) Four Sections on the IV/Invasive Line Assessment – IV/Peripheral Vascular Access Instance – Central Line Instance – Central Line Data – Insertions – AV Fistula

IV Documentation: IV Insertion – IV/Invasive Line Assessment Instance is established – Location, Size, and Line Type Next, document the assessment for the line Insertion – Date, Access Use, Site Observation, etc

IV Documentation: Assessing the Line – IV/Invasive Line Assessment Once the instance is established it will pull forward for each new assessment Document the assessment of the line for the instance

IV Documentation: Intake – I&O Assessment The Medication will automatically pull to the I&O Assessment from the MAR The Intake for the line will be documented manually, based on protocol

IV Documentation: Removal of the IV – IV/Invasive Line Assessment Once the IV is removed, document the removal on the IV/Invasive Line Assessment – Date the line was removed, how it was removed, etc

IV Documentation: Removal of the IV – IV/Invasive Line Assessment Next, inactivate the instance type to indicate the IV is no longer inserted Click the instance, and select inactive

IV Documentation: Removal of the IV – IV/Invasive Line Assessment Gray = Inactive The next time the assessment is documented, this Instance will be gray and collapsed

IV Documentation – EMR I&O Panel Documented Intake will be associated to the Med in the EMR I&O Panel

Exercise: Daily Documentation Use BMV Test Patient (Scan Sheet) Document the Cephazolin IV Insertion – IV/Invasive Line Assessment Document intake for Cephazolin – Document the Intake and Output Assessment Assess the IV Line indicating there is drainage from the IV Site – IV/Invasive Line Assessment Document the removal of the IV – IV/Invasive Line Assessment Document assessment Inactivate instance type

Downtime Two types of Downtime – Unplanned Downtime – Planned Downtime Unplanned: Summit Downtime Software will be available w/MT 6.0 – Summit takes hourly snapshots of pertinent Meditech Reports Saves the reports to a separate server Provides the ability to print pertinent patient information when Meditech is unavailable – Kardex – Active Orders – Downtime MARs – Last Vitals, Intake & Output – Census Planned Downtime: All users are alerted of the downtime, and reports are printed directly from Meditech Instructions will be provided as a reference in the event that there is unplanned or planned downtime

Downtime Planned Downtime – Print the following reports from Meditech – Nursing Kardex (nursing units) – Unit Nursing Census (nursing units) – Care Summary (nursing units) (when available) – 48 Hour MAR (nursing units) – Active Orders Report – Pharmacy Patient Profiles (pharmacy only) Un Planned Downtime – Print the following reports from Summit – Nursing Kardex (nursing units) – Unit Nursing Census (nursing units) – Care Summary (nursing units) – 48 Hour MAR (nursing units) – Active Orders Report – Pharmacy Patient Profiles (pharmacy only)