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
Find patient: REHAB,TRAIN
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 4031

2. Meditech 6.0 Upgrade
Rehab 2

3. Acronyms PCS: Patient Care System EMR: Electronic Medical Record
Intervention and Outcome Documentation
Notes
EMR: Electronic Medical Record
Review clinical documentation
OM: Order Management
Enter Orders

4. Agenda PCS: Patient Care Systems EMR: Electronic Medical Record
Overview
Status Board
Worklist
Care Planning
Documentation Functions
EMR: Electronic Medical Record
Reviewing patient information

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

6. Rehab Main Menu A Physician Care Manager PCS Status Board EDM Tracker
View Patient Information - EMR
PCS Status Board
Patient Care Desktop (Contains several patient care applications)
Inpatient or ED Worklist Documentation – Assessments/Interventions/Outcomes
EDM Tracker
ED Patient Documentation - Assessments/Interventions
Admissions - Reports
Bed Roster
Discharge Register

7. Rehab Main Menu Reconciliation Menu Imaging and Therapeutic Services
Therapists Desktop – Charge Entry
Reconciliation Reports
Billing Reports
Imaging and Therapeutic Services
Management Routines and Reports
Print Operating List
Report Routine: OR, PAT, Day Surgery Schedules
Provider Look-Up
Routine to Look Up Physician Contact Information

8. PCS: Patient Care Systems

9. Status Board

10. PCS Status Board Patient Assignment 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

11. 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

12. 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

13. Video Demonstration II
PCS Status Board
PCS Status Board

14. Exercise A: Find Patient by Account
Click [Lists]
Click [Find Account]
Type Patient’s Name (Last Name, First Name)
Use assigned REHAB,TRAIN patient
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
Select [My List]
Confirm this new patient has been added to your List

15. Exercise B: Find Patient by Location
Click [Lists]
Click [Find Patient by Inpatient Location]
Select [TEST.MOH Location]
Click [Assignments] - Right hand panel
Place a checkmark to the left of a couple of 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

16. Open Chart

17. Open Chart All Inclusive Patient Care Routine Review Patient Data
Complete Assessment Documentation
Enter Orders

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

19. Open Chart: Patient Header
Medical Record Number
Location, Room, Bed
Age, Sex DOB
Height/Weight/BSA
Allergies
Admit Status
Account Number

20. Worklist

21. Worklist Worklist Open Chart Routines 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

22. Worklist: Standard of Care
Upon registration a Standard of Care Automatically defaults
Vital Signs will display for Rehab automatically
For the first encounter, you will add an intervention set before you begin documenting
To Add an Intervention or Intervention set, click the Add Button

23. Rehab Intervention Sets
Group of Interventions/Assessments
Added based upon services provided
Each set will provide the basic interventions needed for all patients
Additional interventions/assessments can be added as needed

24. Rehab Intervention Sets: Physical Therapy
PT Inpatient Set
PT Inpatient Evaluation
PT Inpatient Visit Note
GRP PT/OT Therapeutic Exercises
GRP Balance Assessment
GRP ROM Assessments
GRP Gross Muscle Strength
PT Inpatient Orthopedic Set
Same as above Plus CPM

25. Rehab Intervention Sets: Occupational Therapy
OT Inpatient Set
OT Inpatient Evaluation
OT Inpatient Visit Note
GRP PT/OT Therapeutic Exercises
GRP Balance Assessments
GRP ROM Assessments

26. Rehab Intervention Sets: SLP
SLP Inpatient Set
SLP Speech - Language Evaluation
SLP Inpatient Visit Note
SLP Bedside Swallow Evaluation

27. Adding a New Intervention Set
Intervention Sets or Individual Interventions may be added to the worklist
Additional Interventions may be added as needed
To add new intervention or set use the [Add] button

28. Add Intervention Set 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

29. Add Intervention Set Routine
Type the name of the intervention set and click enter
Select the Intervention from the List and click save

30. Exercise: Adding a New Intervention Set
From the Status Board Launch the patient’s open chart by placing a checkmark to the left of the patient’s name
From the Worklist, click [add]
Select Intervention Sets
Enter PT, OT, or SLP (Based on your provider type)
Select one of the following
PT Inpatient Set
OT Inpatient Set
SLP Inpatient Set
Click Ok
Confirm that the Interventions display as expected

31. Exercise: Adding a New Intervention
Use the same patient
From the Worklist, click [add]
Select Interventions
Select one of the following
Sensation Assessment
Stair Climbing assessment
SLP Voice Eval
Select the assessment
Click Save
Confirm that the Interventions display as expected

32. Individual Interventions
Tendon Reflex Assessment
Sensation Assessment
Ambulation Assessment
Gait Pattern Assessment
Postural Screen Assessment
Stair Climbing Assessment
Lymphedema Assessment
Extremity Circumference Assessment
Neural Tension Assessment
SLP Modified Barium Swallow
SLP Voice Eval
SLP Fluency Eval
SLP Bedside Swallow Eval
SLP Laryngectomy Eval

33. 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

34. Documentation Overview

35. 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

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

37. Documentation - Questionnaire
Clicking Mode will toggle to Questionnaire Style
You may toggle between Questionnaire and Flowsheet mode at any time within documentation

38. Video Demonstration IV
Documentation
Documentation

39. Exercise D: Documenting Inpatient Eval
Start from the worklist
Place a checkmark in the now column for the Inpatient Evaluation
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 the first Patient Profile Section and click save
Click [Save]
Confirm the last done column updates with the last time the intervention was documented

40. EMR Patient Care Panel Displays PCS Documentation Assessments
Interventions
Outcome
Care Plan

41. Exercise E: Reviewing Documentation - EMR
Click [Patient Care Panel]
Confirm that the [Assessment] Tab Defaults
Select to view the Inpatient Evaluation Documentation
Place a Checkmark to the left of the Assessment Name
Click [View History]
Confirm that 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

42. Break

43. Documentation Frequencies
Assessments and Interventions for the patient display on the worklist
Frequencies vary based upon protocol and physician orders
Frequency column indicates how often to document
Last done column indicates the last time the assessment was documented
Frequencies can be edited as needed based upon a particular Order or Protocol

44. Documentation Functions

45. Documentation – Instance Type
Enables multiple instances of documentation for various body locations, positions or situations
PT Treatment Goals
Click the New PT Short Term Goal text
Enter free text

46. Documentation – Instance Type
Document the fields for the situation/instance
Repeat the instance type documentation for the new Short Term Goal

47. 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

48. Documentation – Expand/Collapse
Clicking the [-] symbol will collapse the field within the section

49. 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

50. Exercise F Part A: Documentation Functions - Back Documenting
Select the [worklist] routine
Select Inpatient Visit Note
Click in the now column for the Inpatient Visit Note
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

51. Exercise H: Review Documentation in EMR
Select [Patient Care Panel] in the EMR
Place a checkmark to the left of the Inpatient Visit Note
Click View History
Confirm that the Inpatient Visit Notes displays under the adjusted time (1 hour in the past)
Click [Back]

52. Recall Values

53. Recall Values
Recall Values provides the ability to pull prior documentation to the current assessment
This function is enabled for a select number of assessments
To invoke the recall values function, click the [Recall] Button

54. 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

55. Exercise I: Recall Values
Use your TEST Patient
Document Inpatient Visit Note
Click in the now column to select the Inpatient Eval 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 pertinent medical history
Click to recall the entire assessment: select to the right of the Inpatient Eval
Confirm the entire assessment has recalled
Review all documentation to ensure accuracy
Click Save

56. Care Plan

57. Rehab Problems/Goal/Plan
Short Term Goals, Long Term Goals, and Treatment Plans are established in the Inpatient Evaluation

58. Exercise: Documenting Patient Goals and Rehab Treatment Plan
Document the inpatient evaluation
Place a checkmark in the now column
Click Document
Click Mode to toggle to questionnaire mode
Scroll to the bottom of the assessment and find the PT Treatment Goals
Indicate two short term goals
Click new short term goal to start an instance and free text the first goal
Document the assessment

59. Exercise: Documenting Patient Goals and Rehab Treatment Plan
Click new short term goal to start a second instance and free text the second goal
Document the assessment
Create a new instance for a long term goal
Document the patients treatment plan

60. Review the Goals in the Rehab Summary Panel
Click Clinical Panels
Select Rehab Summary Panel
Confirm that the Rehab Long Term Goals, Short Term Goals, and Recommendations display

61. To Document ED patients
PCS Status Board
Lists
Any Outpatient Location
ED.MH
Find Patient (In TEST: May need to use previous date)
Worklist
Add
Find and Select ED Intervention

62. ED Interventions ED PT Evaluation ED OT Evaluation
ED SLP Bedside Swallow Eval
ED SLP Speech Language Eval

63. Open Practice Session Practice Documenting – Assessment Review
PT Inpatient Set
PT Inpatient Evaluation
PT Inpatient Visit Note
GRP PT/OT Therapeutic Exercises
GRP Balance Assessment
GRP ROM Assessments
GRP Gross Muscle Strength
PT Inpatient Orthopedic Set
Same as above Plus CPM
OT Inpatient Set
OT Inpatient Evaluation
OT Inpatient Visit Note
GRP Balance Assessments

64. OM/EMR Training

65. 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

66. 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.

67. 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.

68. “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.

69. 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.

70. 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.

71. 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.

72. 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.

73. 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.

74. 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.

75. 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.

76. 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.

77. 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.

78. 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.

79. 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.

80. 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.

81. 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.

82. 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.

83. 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.

84. 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.

85. 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.

86. 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.

87. 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.

88. 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.

89. EMR
Electronic Medical Record (EMR)

90. 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?

91. 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?