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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 x 4031

  2. Meditech 6.0 Upgrade RN OB/NB 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 • OM: Order Management • How to Enter Orders • Clinical Data Screen • EMR: Electronic Medical Record • Reviewing patient information

  5. Video Demonstration I New Admission and Care Plan Process New Admission and Care Plan Process

  6. Nursing 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

  7. Status Board

  8. 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

  9. 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

  10. 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

  11. Video Demonstration II PCS Status Board PCS Status Board

  12. Exercise A: Find Patient by Location • Click [Lists] • Click [Find Patient by Inpatient Location] • Select [Test MVH 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

  13. Exercise B: Find Patient by Account • Click [Lists] • Click [Find Account] • Type Patient’s Name (Last Name, First Name) • Use the first Patient on the card taped to your PC. • 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

  14. Open Chart

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

  16. 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 • Enter Allergies • Enter Home Medications • Enter/Review Patient information EMR OM PCS

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

  18. Worklist

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

  20. Worklist: OB Standard of Care • Upon registration a Standard of Care Automatically defaults • Location Specific List of Interventions

  21. Care Plan

  22. Adding the Plan of Care • In Meditech, the first step for a new admission is to add the Care Plan • Select a location specific Care Plan • Includes Problems, Outcomes, Interventions common to any patient admitted to the particular location • Once the patient has been fully assessed the Care Plan will be individualized

  23. OB Delivery Care Plan • Location specific Care Plan includes documentation common to any patient admitted to the particular Location • Care Plan Components • Admission, Daily, and Physical Assessments • Pain Admission, Physical, and Daily Assessments Pain

  24. After Delivery… The specific focus of care selection for delivery (Vaginal, C/S, Perinatal Loss) will add: • Appropriate Recovery Documentation • Appropriate PP Shift Documentation • Appropriate Teaching Records • Discharge Documentation

  25. Newborn Care Plan • Location specific Care Plan includes documentation common to any patient admitted to the particular Location • Care Plan Components • Admission, Daily, and Physical Assessments • Pain • Feeding & Elimination • Discharge Admission, Physical, and Daily Assessments Pain Feeding & Elimination Discharge

  26. 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

  27. Video Demonstration III Open Chart/Worklist/Add Care Plan Open Chart Worklist Add Care Plan

  28. Exercise C: Open Chart/Worklist/Care Plan • Use the first TEST Patient on your PC paper • 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 [Plan of Care] – Right Hand Panel • Click [Add] – Footer Button • Select Care Plan: OB DELIVERY Plan • Click [Save] – Footer Button • Review the Care Plan Components • 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

  29. Admission Documentation • The next step in the care planning process is to complete all admission documentation and physical assessments • Admission Assessments display separately on the worklist • Provides clarity as to which assessments have been documented vs. those that have not • Provides the ability to document one assessment or multiple assessments at one time • Same assessments are documented on admission as throughout the patients stay • Provides the ability to view documentation over time • Provides the ability to compare the current state to the state of the patient upon admission

  30. Documentation Overview

  31. 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

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

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

  34. Video Demonstration IV Documentation Documentation

  35. Exercise D: Documenting PMH • Use the first TEST Patient on your PC paper • 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 as None Reported • Click [Save] • Confirm the last done column updates with the last time the intervention was documented

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

  37. Exercise E: Reviewing Documentation - EMR • Use the first TEST Patient on your PC • Click [Patient Care Panel] • Confirm that the [Assessment] Tab Defaults • 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

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

  39. Individualizing the Plan of Care

  40. OB Individualized Focus of Care • The Joint Commission Requires that each Care Plan be Individualized • Individualized Focus of Care Intervention • Tool to assist with care plan customization • Documentation occurs • After delivery to choose the appropriate selection • After the admission and physical assessments have been completed, as appropriate • When additional problems are indentified, PRN • Based upon the selections, problems and associated interventions will be suggested

  41. NB Individualized Focus of Care • Documentation on the focus of care occurs as problems are identified, PRN

  42. Individualized Focus of Care • Upon saving the focus of care selections, a list of problems is presented • Here, Vaginal Delivery and Diabetes (GDM/IDM) was selected

  43. Adding Problems • Place a checkmark to the left of every Problem presented • Click [Ok]

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

  45. 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

  46. Video Demonstration V Individualizing the Plan of Care Individualizing the Plan of Care

  47. Exercise F: Individualized Focus of Care • Use the first TEST Patient on your PC • Start from the worklist • Find the *Individualized Focus of Care –OB Intervention • Click in the now column • Click [Document] • Select: Vaginal Delivery, Diabetes (GDM/IDM) • Click [Save] • A List of Suggested Problems should display • Place a checkmark next to all and Save. • Click [Plan of Care] – Right Hand Panel • Confirm four new problems have been added

  48. Individualizing the Problem and Outcome • The next step in the care plan process will be to further individualize the problem and outcome • Problem • Indicate the specifics to which the problem relates • Outcome • Indicate specific goals that are being set to achieve the outcome

  49. Individualizing the Problem • Once the problems have been added • Select the Problem tab • Click to edit the item detail field to indicate the disease process for which the problem is related

  50. Exercise G: Customizing the Problem • Use the first TEST Patient on your PC • From the Care Plan Routine – Click the [Problem] Tab • Click in the item detail column for the Problem: Pain • Click [Edit] to enter text for the Problem • Indicate that this problem is “Related to vaginal delivery, gr 3 with a peri-urethral laceration” • Click [Save] • Notice an “I” Displays in the Item detail column • Click the I to view the Item Detail • Confirm the newly documented info displays • Click [Back] to return to the plan of care