1. Computerized Physician Documentation Emergency Department September 2012

2. Objective To enter patient documentation – Meditech (hospital, office, and home) – Citrix (office and home use)

3. From the Tracker Board Step 1: Highlight the patient you want to document on Step 2: Click on DOCUMENT on right side of screen #1 #2

4. If Previous Documentation This screen appears once you click on Document, showing all Physician documentation on this patient Click on Enter New for new documentation

5. List of Documentation If you care to continue Documentation already started, click on the line you are continuing. You will be taken to the report. Then click Edit/Amend. (red circle)

6. Mine vs. All The Mine button allows you to view only those reports documented by you. ALL will allow you to see all reports on this patient. Click Mine to see only yours.

7. Next Screen After ENTER NEW Choose the desired Template and double click 1 2 Initial Screen Once template clicked Blue Highlight bar appears

8. General Adult SECTION LABELS HPI History of Present Illness ROS Review of Systems PE Physical Exam MDM Medical Decision Making Depart Discharge Can only view one section at a time.

9. Documenting Nursing Documentation will default in if RN has completed assessments (ex: reports CHF, reports MI…)

10. Document Click on item desired Drop Down Box may appear Area shaded in darker blue relates to block on right Use Search Box to start typing. List will shorten based on letters typed Some fields will allow more than one check, others only one. Click OK/Next to go to next component (line or query)

11. How to Document – Once this information is complete, select OK/Next. Will loop you to next item to document May also go directly to another section by clicking on it Some components have multiple choice selections Choose by clicking on desired responses To use all responses, document abnormal first, then click normal at top Any item with a * next to it is a required field

12. How to Document – Continue with OK/Next to go on to next screen until all screens are completed – For dates, T = today; T-1 = yesterday, etc. – For times, N = Now (current time on computer) Times are in military time – 8:00 am = 0800 – 8:00 pm = 2000 – Any comments may be made in the open area at the bottom of the screen. – To FILE: Click on Submit You will be asked for your fingerprint

13. Section Buttons OK/Next: Inputs user’s Information and goes to next component, the one below it OK: inputs information, does not go to the next component Cancel: cancels any new information just put into the component

14. Plus and Minus Signs A plus sign shows that there is more detail if you click and open A minus sign compresses the topic – can always be opened again by clicking

15. Options If click bubble at bottom, can free text When click OK, will populate field 1 2 3

16. Comment Field Comment: Refers to space highlighted in darker blue on left. When documented, appears as a bubble. Last bubble above Comment allows free text and adds in actual space

17. Comments Click button next to blank And field will appear to fill in 1 2

18. Normal Button 1. Click on Normal 2. Click OK 3. Predetermined values will automatically populate the fields 1 13

19. System Normals To get system normals, double click header. (HPI, ROS, PE, etc) This screen will appear. It allows you to default normals for the systems not affected at this visit into your documentation. Click Preview before using to see normals

20. Typing Free Text An open box (free text) allows for charts (such as these VS) to be brought into the chart An open box also allows you to free text items. Navigate between the Stop Codes to add pertinent information. [ ] V.S. from Nursing Documentation

21. Next Stop (F2) Next Stop takes you to the next set of Stop codes [ ] to allow you to move through a canned text

22. Functions of Free Text Screen Data Formats allows you to enter information from clinical review Text provides canned text Next Stop (F2) takes you in the free text space to the next field to fill in OK/Next keeps current data and goes automatically to the next query OK keeps data in field Cancel leaves field and takes data out Add Section provides detailed templates for more information Normal allows choice of inputting normal values Quick Save saves and allows you to resume next time you enter patient Submit files as permanent part of chart. CANNOT EDIT afterwards

23. Free Text Buttons Buttons work similarly to Word. Free Text Buttons listed above

24. Scroll Bars Please look for scroll bars that denote there is more to the screen than is appearing

25. Hints to Charting Click on any outliers first individually. Then click on top of column that Is left and the rest will default in Example: Clicked individually on: Oriented x3 Facial droop Speech slurred Then clicked on N at top for N – all bubbles left completed with “N”

26. Add a Section To add more detail based on chief complaint, Click on Add Section and a list similar to the one above will appear

27. Data Formats / Text To add labs, etc. (1) click on Data Formats (2) then click on appropriate component (3) allows data to be pulled in from elsewhere 2 1

28. Quick Save Quick Save button allows you to save your data and come back later to finish without viewing what you have charted. It does not complete your documentation. To file as part of record, use Submit.

29. Charting after Quick Save When returning after a Quick Save, use Resume button. You will return to the original document.

30. To Sign Attendings to sign: – Click Draft or Quick Save to come back later – Click Submit and then Signed to complete Will be able to add addendum only Will not be able to edit once signed Residents/Medical Students to sign: – Click Submit – Choose a Co-Signer – Choose Draft

31. To File Documentation Pending – Similar to Draft Draft – Used by Residents – Can also be used to Save Signed – Used by ED attending to finalize Cancelled – Needs reason – reason is free text Co-Signer – Is required for all Res/MS – Choose attending provider name for this patient Required Data – Unable to sign before required fields completed – Takes you directly to only those components Return – Takes you back to chart from where you left off

32. Required Fields Signed will not be highlighted until all required fields are completed. Once Required Fields are complete, will be low-lit and Signed will be Highlighted.

33. Cancelled - Needs Reason Reason

34. Notes If you would like to look at how the documentation will appear in report form, press F12 on keyboard Any item with a * is a Required Field If Sign is not lit, there are Required Fields that need to be completed – Choose Required Fields to finish needed items

35. To Complete after Patient Discharged From Physician Desktop choose PATIENT ROUTINES Choose Physician Documentation near bottom of list Type in patient’s name to choose correct patient 1 2 2 1 3 3

36. To Sign Documentation Then use your fingerprint to sign documentation

37. Documentation is Complete! ESigned is Status needed to have document complete. Other Statuses: Temp Draft Pending Cancelled

38. Don’t Forget to Sign ! From the Tracker Board if Sign is Highlighted

39. ALL Orders/Documentation Have Been Signed by You Sign Button is Low-Lit

40. For Questions The HELP Desk is available 24/7 Reach them at... 216-241-5115 - or - 15115 (in the hospital) Resources: Cathy Rhoades, Nursing IT Analyst cathy.rhoades@csauh.com@csauh.com Diane McGregor, RN – Training & Support Facilitator diane.mcgregor@csauh.com