The Initial Patient Encounter

1. The Initial Patient Encounter PCS Lesson 2

2. Objectives This lesson will describe: • The process by which you document a patient’s admission • The purpose and selection of Standards of Care • The features of your Intervention worklist • How to document on a variety of screen types • How to change the status of completed interventions

3. We will begin by assuming that we just received a new admission who we have added to our status board. Our new admission is Blake Mobley.

4. The first thing we must do to begin documenting on our new patient is click anywhere in the patient row, as highlighted above. Let’s see what would happen if we do this.

5. Clicking on the patient record will cause the row to become highlighted blue. It is very important we always double check to make sure we have selected the correct patient to document on.

6. Another way of making sure we have selected the correct patient is that his / her name appears at the top of the screen in light blue.

7. Once you have clicked on your patient and their name is highlighted, you are ready to begin your admission documentation. To start this process, we will click on the Interventions button on the right side panel menu.

8. Our patient does not have any interventions because he is a new admission. To add interventions, we must click on the “Add Interventions” button at the bottom of the screen.

9. The Intervention Multi-Select Window will automatically appear. For any admission, the very first thing you do is add a Standard of Care.

10. Standards of Care (SOC) are predefined sets of tasks that are performed for all patients on your unit. Every patient will be assigned the appropriate SOC for his / her admission in order to initiate the various assessments that are to be documented during the patient’s hospital visit.

11. To add a Standard of Care to the patient, begin typing SOC in the data entry field of the Intervention Multi-Select window, as shown here.

12. As you type, all of the SOCs will appear in the Multi-Select window. As you can see, there is a large variety of SOCs from which you can choose.

13. Our patient is an adult Med/Surg patient, so we will select the SOC: Med/Surg Adult to add to his Intervention List. To select the desired Standard of Care for our patient, we will click in the empty box to the left of the Intervention name. This will create a check mark in the box, as we see on the screen here.

14. Always make sure your Standards of Care that you want to add have been check-marked. It is not enough to click on the name of the SOC to highlight it blue. Without the checkmark, nothing will be saved. We will add this SOC to our patient by clicking on Add and Exit in the upper right hand corner of the Intervention Multi-Select window.

15. This will add the SOC to your Intervention Worklist. The Intervention Worklist is where we will document the cares we provide for our patients.

16. One thing we notice on our screen is that the Interventions added when we selected a Standard of Care for our patient are the color purple. This is an indication that they have not been saved yet. To save this Standard of Care to our patient, we must click on the word File, found in the upper right hand corner of the screen. Let’s see what happens when we do that.

17. You can see that once we file or save the Standard of Care, the Interventions for our patient no longer appear purple. Let’s discuss what we are seeing on our Intervention Worklist.

18. At the very top of our Intervention Worklist for our patient we see the Document Stamp. The Document Stamp will allow us to retrospectively document Interventions. We are required to back-time our documentation if the care occurred over one hour in the past. For example, if we take a set of vital signs at 9:00 am, we have until 10:00 am to get those vital signs into the computer system without changing the time in the document stamp. We will learn how to back-time our documentation using the document stamp in a separate lesson.

19. The first column in the Intervention Worklist is the Intervention column. Each intervention we have added as part of the Standard of Care displays here.

20. The next column in the Intervention Worklist is the Text/Ord column. The text bubble will show if an Intervention has text added to it. Text can be pre-built or will flow over from order entry. To add and edit text, you can click directly in the text/ord column.

21. The Status column will show whether an Intervention is Active, Complete, or Inactive. An Intervention with an Active (A) status is one that we will routinely be using to document with. Once we have finished documenting on an intervention, we can change the status to Complete (C). We will learn more about how to utilize this column later in the lesson.

22. The Src, or Source column, will show where the Intervention was added from. All of our Interventions were added as a SOC from PCS, so we see a source or PS. Other sources we may see are OE – from Order Entry, and ED – from the Emergency Department.

23. The Frequency column shows the minimum amount of times the Intervention must be documented. The Interventions with a frequency of “On Admission” are the first Interventions we document as part of the admission process. In future lessons we will learn how to document the others.

24. To change a frequency of an Intervention, we can click directly in the Frequency column. Let’s see how we would do this for our Height and Weight Intervention by clicking in the Frequency column for Height and Weight.

25. Clicking in the frequency column will open a screen where we can edit the frequency. To begin this process, we must first click on the Add button.

26. This will pull in the current date and time. Next we have to add our new frequency in the blank frequency box.

27. We want to add a nursing frequency of NURBID to our intervention. To add a nursing frequency, we will type a capital latter N in the frequency box and then press the F9 key on our keyboard to see our list of frequency options. F9

28. Our list of nursing frequencies will appear. Here we have clicked on the one we were looking for – BID Twice a day.

29. Now we must click on the Update button to update our new frequency choice on the screen.

30. Now our new frequency has been added to the top of the screen. We now must click on OK to change our frequency back on the Intervention List.

31. We are now back on our Intervention List. Notice the frequency column for height and weight is green. This means we have to file our new frequency changes. After we file them, we will be able to see the changes reflected in the Frequency column.

32. We have now filed our Intervention worklist and the new frequency of NURBID is showing up in the frequency column for height and weight.

33. The History column shows us when each of the Interventions was last documented in minutes, hours, or days. We have not documented on any of our Interventions, so we are not seeing anything in our history column yet. The History column is also the place where we will edit or correct any mistakes in our documentation. We will learn more about documentation editing in another lesson.

34. The Next Scheduled Column shows us the next two times an Intervention is due to be documented on within the next 24 hours. We will only see these times in the next scheduled column for Interventions with a frequency that Meditech recognizes as a certain time.

35. The Prtcl, or Protocol Column, will display a triangle symbol if the Intervention has an attached policy / protocol that may be useful when documenting. To view the protocol for an Intervention, we will simply click on the Protocol Triangle.

36. The Assoc Data column will pull recent documentation from the EMR / Chart and display it on the screen. To view the recent documentation, all we have to do is click on the triangle in the appropriate Assoc Data column.

37. The Intervention worklist is arranged in order according to the frequencies of the Interventions. The Interventions due soonest are found at the top of the list, followed by those due On Admission, and finally – those listed as PRN, On Discharge, and any other frequency.

38. We can also sort out Intervention list alphabetically. This is often helpful if we have several interventions on our worklist for a patient. To alphabetize your Intervention worklist, you will click on the column header where it says Intervention. Let’s see what this looks like.

39. We can now see our Interventions listed in alphabetical order from A to Z on this screen.

40. To change the screen back to being ordered according to frequency, all you have to do is click on the Next Scheduled Column and the list will rearrange.

41. In this lesson, we are admitting a Med/Surg patient, but the process for patients of all types are similar to this one. We will first document all those items with a frequency of “On Admission.”

42. There are two sets of documents that need to be completed within 24 hours of admission. The first set is the Admission Database and the second set is the past medical history.

43. We will also need to document on our System Flowsheet. This is your patient’s head-to-toe assessment, and is documented upon admission and at regular intervals during the hospital stay.

44. When we are ready to document something, we can open the documentation screen in one of two ways. One way is by clicking on the Intervention name one time so that it is highlighted (as we see on this screen for our Med/Surg System Flowsheet) and then clicking on the word Document at the bottom of the page.

45. After you click on Document, you will have to select the date and time you performed the assessment. If your documentation is within an hour of the time you actually performed the assessment, you can simply click on OK at the bottom of this window. Otherwise, the date and time will need to be changed to reflect the accurate time the assessment was performed.

46. After you have selected a date/time, the “Go To” List will open on the screen. The patient System Flowsheet and the Past Medical History are called Group Assessments. This means they have several pieces that must be documented. We will see this “Go To” window open for either of these Interventions when we are documenting on them. For our Med/Surg System Flowsheet, we will start at the top by clicking on Neurological and work our way down the list.

47. This is the documentation screen that addresses the patient’s neurological status. There are several different types of questions you must answer. Every color on this screen has a meaning. We will explain the color scheme and how to answer the questions as we proceed.

48. The first question is about the patient’s LOC. On the left side of the screen is what you are documenting – in this case the patient’s level of consciousness.

49. The right side of the screen is where you will find the options to use when you are documenting. In this case, the background is the color yellow and the words “Select all that apply” are seen in the left heading. With this type of question you can choose several answers rather than being limited to just one. “Select all that apply” questions will always appear with a yellow background like this one.

50. You can select a response by clicking on the desired selection. When you click on the choice an “x” will appear inside the parentheses and the background will change color. This patient is awake, so we will document that now.