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

2. Acronyms
PCS: Patient Care System
Documentation
Interventions

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

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

5. Status Board

6. 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

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 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

9. Video Demonstration II
PCS Status Board
PCS Status Board

10. 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

11. 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

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
Worklist
Intervention & Outcome Documentation
Write Note
Clinical Data
Enter/Review Patient information
EMR OM
PCS

15. Worklist

16. 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

17. 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

18. 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

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

20. Documentation Overview

21. 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

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

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

24. Video Demonstration IV
Documentation
Documentation

25. 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

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

27. 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

28. Documentation Functions

29. 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

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

31. 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

32. 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

33. 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

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

35. 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

36. 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

37. 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]

38. 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

39. Recall Values

40. 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

41. 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

42. 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

43. Worklist Management

44. 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

45. Item Detail

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

47. 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

48. 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

49. 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

50. 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

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

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

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

54. 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

55. 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

56. 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)

57. 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

58. Change View
The worklist displays active and discharge status items (only) by default
To bring inactive entries to view click Change View

59. 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

60. 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

61. 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

62. 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

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

64. 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

65. Write Note You may choose to document a free text note
Or, select Text to enter a canned text (pre populated note)

66. 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.

67. 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

68. 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

69. 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

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

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

72. Patient Reports
Click ok to print the report

73. 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

74. 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

75. 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

76. 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:

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