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Before we Begin

Before we Begin

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Before we Begin

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  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 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 Respiratory Therapy Session I

  3. Acronyms • PCS: Patient Care System • Care Planning • Intervention and Outcome Documentation • Medication Documentation • Notes • MAR: Medication Administration Record • Medication Administration Documentation • BMV: Bedside Medication Verification • Scanning Medication Barcodes to verify 5 Rights • EMR: Electronic Medical Record • Review clinical documentation • OM: Order Management • Enter Orders

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

  5. Respiratory Main Menu • List of Routines and Reports • PCS Status Board will provide most patient care routines • Additional routines will be covered in more detail in Session II

  6. Status Board

  7. PCS Status Board Patient Assignment List • 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 Status Board Function Buttons Patient Care Routines & Function Buttons

  8. 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

  9. 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

  10. Video Demonstration II PCS Status Board PCS Status Board

  11. 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

  12. 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 • Click [Lists] • Select [My List] • Confirm this new patient has been added to your List

  13. Open Chart

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

  15. Open Chart • EMR Electronic Medical Record • 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 • View Allergies • View Home Medications • Enter/Review Patient information EMR OM PCS

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

  17. Worklist

  18. Worklist Worklist • Open Chart defaults to the worklist tab • Documentation Routine • Interventions, Assessments, & Outcomes Open Chart Routines Worklist Functions

  19. Worklist: Standard of Care • Upon registration a Standard of Care Automatically defaults • Vital Signs • Assessments also display from the Plan of Care • Pain Assessment • Respiratory Assessment • Teaching Record • Individualized Focus of Care Interventions • Additional Respiratory Interventions will be added via the Individualized Focus of Care

  20. Exercise C: Open Chart/Worklist/Care Plan • 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

  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 Respiratory Assessment • Use the first TEST Patient on your Blue Card • Start from the worklist • Place a checkmark in the now column for the Respiratory Assessment • 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 • 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 Respiratory 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. Individualizing the Plan of Care

  31. Individualized Focus of Care • The Joint Commission Requires that each Care Plan be Individualized • Once Admission Documentation and Physical Assessments have been completed - Customize the Care Plan • Individualized Focus of Care Intervention • Tool to assist with care plan customization • Documented after the admission and physical assessments have been completed • Based upon the focus of care selected, a list of problems will be suggested

  32. Individualized Focus of Care • Upon saving the focus of care selections, a list of problems is presented • (i.e.: Cardiovascular, Glucose Metabolism, and Infection focus of care selections)

  33. Adding Problems • Place a checkmark to the left of the Problem • Select [Add to Care Plan] • Click [Ok]

  34. Individualized Care Plan • The newly added problems will be viewable within Care Plan Routine

  35. Documentation Frequencies • Outcomes, Assessments and Interventions from the care plan display on the Worklist • Outcomes: required to be documented daily and upon discharge • Interventions/Assessments: 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

  36. Exercise F: Individualized Focus of Care • Use the first TEST Patient on your Blue Card • Start from the worklist • Find the *Individualized Focus of Care –M/S/ICU Intervention • Click in the now column • Click [Document] • Select: Neb/MDI Tx, Oxygenation, and Smoking • Click [Save] • A List of Suggested Problems should display • Place a checkmark next to: Airflow Limitation ReqBronchodilation, History of Smoking, and Hypoxemia • Click [Add to Plan of Care – M/S/ICU] • Click [Ok] • Click [Plan of Care] – Right Hand Panel • Confirm three new problems have been added • Add Item Detail to each of the problems to customize the problems

  37. Adding Text to Individualize the Problem • Once the problems have been added, click to edit the item detail for the Problem to indicate the disease process for which the problem is related

  38. Documentation Functions

  39. 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

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

  41. 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

  42. 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

  43. 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

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

  45. 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

  46. Exercise F Part A: Documentation Functions - Back Documenting • Use the first TEST Patient on your Blue Card • Select the [worklist] routine • Select Respiratory Assessment • Click in the now column for the Respiratory Assessment • 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

  47. Exercise G Part B Documentation Functions – Calculator & Instance Type • Document Lung Sounds (Instance Type) • Left Upper: Clear and Left Lower: Rhonchi • Click “New Lung Sounds” and select the drop down arrow to indicate Left Upper. • Document Clear • Click “New Lung Sounds” and select the drop down arrow to indicate Right Upper • Document Rhonchi • Click [Save] • Add steps – Delete and inactivate instances!

  48. Exercise H: Review Documentation in EMR • Select [Patient Care Panel] in the EMR • Place a checkmark to the left of the Respiratory Assessment • Click View History • Confirm that the Respiratory Assessment displays under the adjusted time (1 hour in the past)

  49. Recall Values

  50. 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