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 QMC IP Location
Find patient: EMR TEST
Launch the Open Chart
Click MAR
Enter your PIN – Make sure you know your PIN
If you need to reset your PIN – Please call the support center 5999

2. Meditech 6.0 Upgrade
Nurse Techs
Session I 2

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

4. Nurse Tech Main Menu List of Routines and Reports
PCS Status Board will provide most nursing care routines
Additional routines will be covered in more detail in Session II

5. Status Board

6. PCS Status Board Patient Assignment List/Home Page
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

7. 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

8. 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
Preferred method
My List
Launches your patient assignment list

9. Video Demonstration II
PCS Status Board
PCS Status Board

10. Exercise A: Find Patient by Location
Click [Lists]
Click [Find Patient by Inpatient Location]
Select [Test QMC IP Location]
Click [Assignments] - Right hand panel
Place a checkmark to the left of the following patient’s names
EMR, TESTPATIENTA
EMR, TESTPATIENTB
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

11. Exercise B: Find Patient by Account
Click [Lists]
Click [Find Account]
Type Patient’s Name (Last Name, First Name)
Use the first Patient on your Blue Card
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

12. Open Chart

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

14. 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
Care Planning
Add the Care Plan
Worklist
Intervention & Outcome Documentation
Write Note
Clinical Data
Enter Allergies
Enter Home Medications
Enter/Review Patient information
EMR OM
PCS

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

16. Worklist

17. 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

18. Worklist: Standard of Care
Upon registration a Standard of Care Automatically defaults
Location Specific List of Interventions
Includes Interventions that the CNA will need to document
Provides CNA the opportunity to document even before RN is able to add the Care Plan

19. Worklist
Interventions and Outcomes will display on the worklist as added with the Plan of Care
Clicking the Frequency header will sort the list by frequencies
This will help to clarify which interventions are to be documented upon Admission

20. Exercise C: Open Chart/Worklist
Use the first TEST Patient on your Blue Card
You will be working with the patient from your paper sheet
Click [Lists]
Select [My List]
From your Assignment list, click to the left of the patient’s name to Launch the Open Chart
Confirm the Standard of Care list automatically defaults to the worklist
Click [Worklist]
Confirm the Interventions and Outcomes from the plan of care appear on your worklist
Click the frequency header to sort the worklist by frequencies
This will highlight which interventions should be documented on admission

21. Documentation Overview

22. 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

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

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

25. Video Demonstration IV
Documentation
Documentation

26. Exercise D: Documenting ADL Shift Assessment
Use the first TEST Patient on your Blue Card
Start from the worklist
Place a checkmark in the now column for the ADL Shift Record
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 patient’s lunch
Click [Save]
Confirm the last done column updates with the last time the intervention was documented

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

28. Exercise E: Reviewing Documentation - EMR
Use the first TEST Patient on your Blue Card
Click [Patient Care Panel]
Confirm that the [Assessment] Tab Defaults
Select to view the ADL Shift Record 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

29. Break
1 Hour 30 Minutes
(15 Minute Break)

30. Documentation Functions

31. Documentation Functions
Temperature, Height and Weight Queries
Enable you to toggle between English and Metric Units within documentation
Instance Type Queries
Enable multiple instances of documentation for various body locations or situations
IV Insertions, Orthostatic Vital Signs, etc

32. Documentation - Calculator
Enables you to toggle between English and Metric Units
Regardless of the units of documentation, the display will default to English

33. Documentation – Instance Type
Enables multiple instances of documentation for various body locations, positions or situations
IV Insertions, Orthostatic Vital Signs
Click the drop down arrow to invoke the group response
Select the body location/situation
Click Ok

34. 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

35. 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

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

37. 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

38. Exercise F Part A: Documentation Functions - Back Documenting
Use the first TEST Patient on your Blue Card
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

39. 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]

40. 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

41. Worklist Management

42. 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

43. Item Detail

44. Item Detail Column Item Detail Column P: Protocol A: Associated Data
I: Item Detail

45. Item Detail Clicking the Icons will launch the item detail screen
Within Item Detail there are multiple tabs
Detail, History, Flowsheet, and Associated Data

46. Item Detail Tabs Detail History Flowsheet Associated data
Info about Intervention
Intervention text (Post it note)
History
Audit trail of changes made to the intervention
Flowsheet
Documentation View in Flowsheet mode
Associated data
View of Data Fields related to the particular intervention

47. 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

48. 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

49. Item Detail: Edit Text
Enter the text that you wish to display with the intervention
Click save

50. Item Detail Text
The item detail will be viewable by clicking the “I” from the worklist or within the assessment

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

52. Exercise I: Item Detail/Editing
Use the first TEST Patient on your Blue Card
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

53. Exercise J: Item Detail Text
Use the first TEST Patient on your Blue Card
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
This is comparable to a post it note or Edit Text in MT Magic
Please note: The last documented text will print with the medical record

54. Break
3 Hours
15 Minute Break

55. OM/EMR Training

56. 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

57. 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.

58. 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.

59. “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.

60. 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.

61. 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.

62. 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.

63. 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.

64. 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.

65. 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.

66. 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.

67. 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.

68. 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.

69. 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.

70. 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.

71. 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.

72. 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.

73. 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.

74. 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.

75. 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.

76. 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.

77. 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.

78. 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.

79. 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.

80. EMR
Electronic Medical Record (EMR)