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Meditech Training Manual Emergency Department Management (EDM) Second Edition Jonna Bobeck BSN, RN, CEN
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Table of Contents SECTION 1
4
WHAT IS EMERGENCY DEPARTMENT MANAGEMENT SECTION 2
4-5
TRACKER REVIEW SECTION 3
5-6
EDM TOOLBAR SECTION 4
6-7
FUNCTION KEYS SECTION 5
7-10
INTEGRATED DESKTOP TRACKER BUTTONS SECTION 6
10-13
G INTO EDM SECTION 7
14-20
TRIAGE SECTION 8
21-25
VACCINE/MDRO/ALLERGIES SECTION 9
26-44
MEDICATION RECONCILIATION SECTION 10
45-46
VITAL SIGNS SECTION 11
47-48
PSYCHOSOCIAL SECTION 12
49-51
ASSIGN ROOM AND NURSE SECTION 13
52-53
CHARTING ASSESSMENTS SECTION 14 TREATMENT INDICATORS/INTERVENTIONS
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EDM SECTION 15
65-83
MEDICATION ORDERING SECTION 16
83-104
ELECTRONIC MEDICATION ISTRATION RECORD (EMAR) SECTION 17
104-106
CHANGING CHIEF COMPLAINT SECTION 18
107-109
CHANGING STATUS EVENT SECTION 19
110-114
DEPARTURE AND DISCHARGE DOCUMENTATION SECTION 20
115-116
ISSION DOCUMENTATION SECTION 21
117-119
DOCUMENTING ON WRONG RECORD SECTION 22
120-121
EDITING RECORDS SECTION 23
122-125
PATIENT’S ACCIDENTALLY DEPARTED SECTION 24
126-139
CLINICAL REVIEW SECTION 25
140-160
PATIENT CARE INQUIRY (PCI) APPENDIX A
161-169
CHIEF COMPLAINTS APPENCIX B___________________________________________________________________________________170-171 ASSESSMENT LIST APPENDIX C___________________________________________________________________________________172-177 TREATMENT INDICATORS
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Emergency Department Management (EDM) Instructions Section 1: What is Emergency Department Management? EDM was implemented at Pullman Regional Hospital to improve patient care in the emergency department. This is accomplished by improving efficiency related to documentation. Greater efficiency can be accomplished by simplifying, streamlining, standardizing and enhancing the documentation process through computerization of the patient care record. Information flows easily within all setting of Pullman Regional Hospital and other facilities within the INHS network while maintaining patient privacy. Section 2: Tracker Review Prior to logging in you will be able to visualize the public tracker. After logging in you will visualize the private tracker. To quickly view the encounter, click on the patient’s name or click the Summary button. The encounter is a real time view of the patient’s progress in the emergency department. It will show everything that is current and done for the patient. You will see the patient’s name, age, chief complaint, priority, assigned nurse mnemonic, status event, time in department, results indicator area, integrated desktop, and tool bar. HELPFUL HINTS:
• To quickly view the encounter, click on the patient’s name. • To assign a room number, click on the room number located at the top left of the screen. • To change/update the chief complain, click on the chief complaint. • To change the status event, click on the status event. • To view lab, radiology, ultrasound, CT and etc., click on the results indicator area. • To to be the primary nurse, click on the button on the integrated desktop on the far right of the screen. • To access PCI, click on the PCI button on the integrated desktop.
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• To access Clinical Review click the Review button on the integrated desktop. • To chart Treatments click the NUR button in the results indicator area. • Quickly access the electronic medical record by clicking the eMAR button on the integrated desktop.
The Private Tracker
Section 3: EDM Tool Bar
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The EDM tool bar is found on the far right of the screen (highlighted in red) and works as follows: • • • • • • • • • •
Green check = OK or file Red “X” = exits you out of the current screen or pop-up Question mark = help Binoculars = look-up patient information of certain screens Green star/red X = session management, magic key menu Tools = access to a calculator Blue flower = special function key Green check all = checks all items in order sets in physician order management Blue arrows = up, down, back and forth in one field Green arrows = page up and page down
Section 4: Function Keys •
F12 = OK/file, exits and files entries
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Shift + F12 = hot key menu/magic menu F11 = exits and does not file or save entries F10 = line feeds to erase current field F9 = lookup key for list of choices F8 = page down ( same as green arrow down) Shift +F8 = access on-line documentation F7 = page up (same as green arrow up) F6 = takes you back to the previous field F5 = auto fill F4 = Gives you access to “canned text”
SECTION 5: Integrated Desktop Tracker Buttons Meditech’s Emergency Department Management (EDM) application includes a Patient Tracker Integrated Desktop. This application gives staff a central point of data entry for documenting the daily treatment of patients and for managing the flow of patients through the system. The EDM system, which tracks patient test results, medication orders, and vital signs, serves as a communication tool between physicians, nurses, and the departments with which the Emergency Department staff interacts. Most of your documentation will be done from one of these tracker buttons. The integrated desktop is highlighted in red below:
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TRACKER BUTTONS (INTEGRATED DESKTOP) •
• • • • • •
• • • • •
Summary: Enables you to view or print out the patient’s complete EDM record for the visit. Can also click on the patient’s name or highlight the patient’s name and right arrow. Ret: Not used Room/Staff (Rm/Staff): Let’s you assign a room and staff to a patient. Usually done by charge nurse in triage. Sign up: assigns you to the patient. Triage/Document (Trg/Doc): This will take you to the triage/documentation screen where assessments and interventions are documented. Reconcile: Takes you to the Medication Reconciliation screen. Advanced Status Event (Adv St Ev): Gives you a limited selection of status events to change to. You may also change the status event by clicking directly on it. By using the method you will get the full list of events. Pt Notes: Allows for general patient notes to be added to your documentation. Orders and Order Summary: Here you can place and view orders. eMAR: Takes you to the electronic medical record. Review: Takes you to Clinical Review PCI: Allows you to view specific patient care information.
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Depart: This is where discharge functions are performed. If the patient is going home you will need to hit depart. If the patient is itted you will depart them and update the status event. Comment: Allows you to type in a comment. You can do this by clicking the Comment tab or clicking under the HM in the results indicator area. When a comment is left an * will appear. Just click the * to view. To delete the comment open and delete then file. See screen shots below:
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Trackers: Allows you to view current patients and discharged patients. Forms: Use to print medication reconciliation form for itted patients.
Section 6: g Into EDM There are two ways to sign in to EDM. From the computer desktop go to the icon “HCIS” and double click on it. You will see a screen labeled MIS Directories. Choose #1 which is “live”, and this should take you to a screen.
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Enter your ID and .
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You will be taken to the EDM Main Menu. From here you choose where you want to go. To reach the Private Tracker click on All Patients.
This will take you to the private tracker and you are ready to begin charting. If the public tracker is already on the computer screen, simply hit right Ctrl key and proceed to with name and . At this point you are ready to chart on your patient. Be sure you are charting on the correct patient. Click on the patient you want to chart on and it will highlight blue.
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Helpful hints for charting see highlighted areas below: • • • •
/ = F9 lookup (may not use free text). : = Can use free text. ? = Yes or no question. All you have to do is type Y or N. + = There is text in the background. To access hit Shift + F8.
Examples in red below:
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Section 7: Triage The first thing to be done in triage is to assign a chief complaint. To begin, select the correct patient and click on the Trg/Doc button from the private tracker. Click the “Edit” button next to the chief complaint field near the top of the screen.
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Hit F9 and all the accepted chief complaints come up. Choose which complaint is appropriate for the patient. You may also type in the mnemonic. For a complete list of chief complaints see appendix A.
Now you are ready to go to the triage screen. Under Assessments click the “+” on the left and then on triage, go over to the Integrated Desktop on the right of the screen and click Document or just type “D” on the keyboard. Your cursor will go to the Date, just type “T” for today. Next, the cursor will move to the time box, type “N” for now.
You are now ready to begin the triage assessment.
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Start with answering the questions at the top of the screen (exposure, and interpreter) if applicable. Arrived By/ and With/ are F9 look-up or you may type in the correct mnemonic. Next is your note in the Objective/Subjective field. This is free text, when finished hit F12 to file. After you hit F12 and file your Objective/Subjective History your cursor will be blinking in the Medical/Surgical Hx area. Fill out Medical/Surgical Hx; this is a free text field. You must hit enter F12 to move onto the next line. Click on Last Tetanus and record the year the last tetanus was given. Hit enter and tab over to Immunizations Current and type “Y” or “N”. Hit enter to Last Menstrual Period and type in date. Tab through and fill out number of pregnancies, live births, and abortions. Fill in Primary Care Physician and use F9 to look up the correct provider. Enter or tab over to weight and enter in LB, hit enter until you reach height and fill in each box. Enter the patient’s primary
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physician and click “OK”. Now you are back at the Trg/Doc screen. Near the bottom of the screen is Status Event (TRG), click this button and hit Document.
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Choose your new status event and Hit Ok or F12 to file.
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Lastly assign a priority. Click the Priority button at the bottom of the private tracker screen and hit Document, a white box will appear, hit F9 to look up and assign the appropriate priority from 1 – 5.
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Section 8: Vaccine/MDRO/Allergies
Now let’s chart the patient’s vaccines, MRSA, VRE, and allergies. Highlight Vaccine/MDRO/Allergies and hit “D” or click the Document button. Type “N” for now and this is what the screen will look like.
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Type “Y” in the Update Allergies white box and you will be taken to the Allergy Management screen as seen here.
Highlight each allergy listed and with patient and click confirm on the Verb Strip. If a new allergy needs to be entered click “New” on right hand of the screen.
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Type in the allergy and a list will appear in large white box. Click on correct allergy and select severity. At the bottom of the screen there is a white box labeled “Reaction”, hit the down arrow and find appropriate reaction and click. Make sure the verified box is checked at bottom right of the screen and file and you will be taken back to the Vaccine/MDRO screen.
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When you have finished entering the patients allergies you will be rerouted back to the Vaccine/MDRO screen. The cursor will be automatically be blinking in the Drug Resistant Organism History Reviewed? Box. Type “Y” and enter to fill in blanks. If the Patient has a documented history of MRSA the fields associated with it will be auto populated. Next the cursor will go to the Have you had the influenza (Flu) Vaccine this season/, type “Y” or “N”. Do the same for the pneumonia box. Hit enter and fill in the white boxes as applicable. When finished click “OK”. You will then be taken to the HOME MEDICATION HISTORY screen as seen below. The cursor will be blinking next to the “Y” in the Update medication list? box, hit enter and you will be taken to Medication Reconciliation.
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Section 9: Medication Reconciliation
The Medication Reconciliation screen will come up two ways. After you have finished entering allergies in triage and click yes in the HOME MEDICATION SCREEN or when you click the blue header in the Trg/Doc screen titled Active Prescriptions/Reported Meds. You will see the patients name, DOB, and unit number at the top of the screen. Below the name will be documented allergies. In the middle of the screen will be the main headers: Home Meds and Prescriptions or Discontinued Home Meds if applicable. The large white box will have no headers if the patient
EDM new and no meds have been reported. From here click on Upd Med List from the Integrated Desktop on the right.
This will open the update med list screen.
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Begin typing the home medication here. This is a type-ahead functionality and the search will narrow down the choices of medications by the more letters that are typed. The begins in their Favorite List but the system will automatically go to “Go to All Meds” if the medication is not found. As you type medications from a database of 33,000 will come up. For example, if you type (tyl) all forms of Tylenol will appear. In this example, tyl has been entered, narrowing the search down to medications beginning with these three letters. Highlight by clicking with your mouse or using your arrow up/down key to select the desired medication. Click on the Select button at the bottom of the screen when finished.
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This will take you to the screen where you can manually fill in Dose, Units, Route, and Frequency.
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You may also auto populate the correct Dose, Unit, and Route fields by clicking the blue string. Click done when finished.
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On this same screen instructions can be typed in. For example, patients who are taking Coumadin on Monday, Wednesday, and Friday can have that put into this section.
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The box below Instructions is Comments. This is where you want to enter the indication for the medication. Click on the down arrow
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A pop up box will appear, choose #2 Indication for med.
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A list of indications will appear, choose what is appropriate for your patient.
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The indication will auto populate a white box when you click what you want, then click OK.
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If the entries are correct, select Done.
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After you have clicked on Done, you will be taken back to the Last Taken screen where you can enter the date and time when the patient last took their medications.
EDM You may also print the Monograph of a medication simply by clicking the Monograph button.
The Monograph will appear in a pop-up box as seen below.
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You have now launched the Last Taken screen.
Click on the correct date on the calendar and enter the time the patient took their mediation. Only enter the dose if it different than what is reported in the medication reconciliation screen. Click “OK” when finished. You will now see you medication under the header Home Meds and Prescriptions. Highlight the review button if all the information is correct and click Submit on the Verb Strip, you will be taken to the Medication Reconciliation Summary screen. If your information is correct click “OK”. If you need to make changes you can click cancel and start over.
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Finally click the Return button and you will be taken back to the Vaccine/MDRO HOME MEDICATION SCREEN.
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Fill in the patient’s pharmacy and disposition with free text. Use the F9 key and choose what is appropriate for the Medication history box. Type “Y” or “N” in the ASA, NSAIDS, anticoagulants and herbal products fields. You may also free text in the large white box after the remedies. Enter down to the Home Med Hx field and hit F9 and choose the appropriate response. Type “Y” or “N” for pharmacy consult and a reason if need be. You may type additional comments in the white comment field at the bottom of the screen. When finished click “OK” and you will be taken to the Trg/Doc screen. Click on ALLERGY BAND PRINTING and type “Y”. Your allergy band will print in triage. Be sure to apply to patient.
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The screen shot below shows what the Private Tracker results indicator area will look like when you have completed documenting home medications: The red HM indicates that someone verified allergies and MDROs but did not complete the meds and checked “nursing f/u” in the drop down menu. The green HM indicates that both the allergies/MDRO and home medication have been completed and the nurse marked “completed” in the drop down menu. If the area is blank neither the allergies/MDRO or home medication screens have been completed.
HM = Nursing F/U selected on Home Med Hx Status HM = Complete selected on Home Med Hx Status Blank = MDRO/Vaccine Assessment not filed
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Section 10: Vital Signs Highlight vital signs and hit “D” or click on the Document button. Type “N” for now or type in the time the vital were assessed.
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Type in results for Temp, Pulse, Resp., BP etc. For the method, rhythm, site etc. use the F9 lookups to select appropriate response or type the mnemonic. Type in Capillary Refill, press enter. Fill in O2 sat and press enter. Type in LPM of O2 and press enter, O2 type/ can use F9 lookup and choose appropriate response. Type “Y” or “N” for cardiac monitor and orthostatic BP. If yes for orthostatic BP a pop up screen will appear, fill in each field file with F12 and return to VS screen. In the Pain? Box type “Y” or “N” and press enter. Next type in intensity from 1 – 10 and press enter. There is a “+” outside the Intensity and Cardiac Monitor box which means there is hidden text, to access hit F8. Location: is free text. In the field for Pain Quality/: use the F9 function key and choose appropriate response. Comment: is free text. Hit F12 to file.
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Section 11: Psychosocial Click on Psychosocial and hit “D” or click on Document. Type “N” for now.
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Use F9 to look up and fill in Functional Impairment, Factors Affecting Ability to Learn, and Living Arrangements. Do you feel concerned for your safety is a required field. Type “Y” or “N”. Enter down to information obtained from: and fill in appropriate box with a “Y” or “N”. Comment field at the bottom of the screen is free text. This may be used if a person does not feel safe and you need to explain. Click OK or F12 to file. Select the red “X” or hit F11 to exit this screen and return to the tracker.
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Section 12: Assign Room and Nurse With the patient highlighted from the private tracker, click on Rm/Staff button on the right side of the screen in the Integrated Desktop, click in the room box type in a room number or choose from list with F9.
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If the primary nurse is known their name can be put in at this time by typing in his/her mnemonic in the nurse box. Hit F12 to file and save. If the charge or triage nurse has not already assigned the patient to you the first step is to for the patient. To do this, make sure the patient you want is highlighted on the private tracker and then click the button on the right hand of the screen on the Integrated Desktop.
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Section 13: Charting Assessments The assessments are linked to the patient’s Chief Complaint. For example, a patient with Irregular Heart Beat will automatically generate Cardiac and Respiratory assessments. As a reminder, to chart an assessment, there are a few things to look at. Some of the fields are free text, designated by a “ : “. Others are look up menus designated by “ / “ hit the F9 key and this is where you choose from a list (or type the mnemonic). When you see “ ? “ you type “Y” or “N” for yes or no.
Click on the assessment then hit Document on the integrated desktop or type “D”. Furthermore, you may add additional assessments or treatments for your patient by clicking the assessment or treatment buttons. Next type “D” or click Document. A white box will appear, hit
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F9 or type the mnemonic to add assessment or treatment. From this list choose the one you want to complete. Hit F12 to file. For a complete list of assessments please see appendix B.
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Section 14: Treatments Indicators/Interventions With Treatment Indicators it is very important to place orders on the patient before documenting. This will bring the documentation to the Trg/Doc screen. Place orders through Physician Order Management (POM) by highlighting your patient and clicking the Orders button on the EDM Tracker and then in POM. When order sets are used click on the Order Sets button instead. Here is an example of Treatments/Interventions in POM. Most of the orders have been in place for a while, but some new treatments will now exist. Notice the Category is EMERGENCY DEPARTMENT and there is an “ER” or “ED” at the end of each order.
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Now let’s chart some treatment indicators. This would be interventions we do for our patient’s, for example, IV insertion, IV removal, foley catheters, and ice packs. The physician will enter orders which then will generate treatment indicators for the nurse. When new orders are placed the “NUR” indicator on the Private Tracker will turn red alerting the nurse there are new treatments ordered.
The nurse can either click on the red “NUR” or click Trg/Doc to launch the Patient Triage/Documentation screen to view and chart his or hers treatments.
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The new treatment indicator will be highlighted in green under the blue “Treatments” header. Click the green treatment indicator and then document to begin charting. For example, click the green Foley Catheter and click Document.
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When finished with your charting click “OK”.
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The treatment indicator will now turn black and a “+” will appear in the left column letting the nurse know the treatment is complete.
When all the treatments have been documented the NUR indicator will change to Green. One exception is the IV DC. It will not trigger the indicator to change color since it will not get documented until the end of the visit.
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Patient Summary View:
Documented interventions will show on the Patient Summary in the Treatment section.
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You may want to add treatments. To chart on a treatment that is not generated by the physician orders, you can add an additional treatment from the treatment list, for example, bedside commode. To do this, arrow down to, or click on Treatments so the blue treatments header is highlighted. Hit “D” or click Document button to add treatment.
From here a white box will appear type in the mnemonic of the treatment or hit F9 to lookup. Once the list pops up, select the treatment you want to chart on.
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Select number 9 Bedside Commode and you will automatically start charting.
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Click “OK” when finished and you will see the Bedside Commode charting is under the treatments section in black with the “+” to the left of the column
You use the same process to add assessments. You will notice when assessments are completed and filed they will have a “+” next to them on the left side of the screen just like the treatments. You can click on the (+) to expand the treatments or assessments. For a complete list of treatments and interventions see appendix C and D.
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Section 15: Medication Ordering Medication ordering allows us to interface the ordering process with Pharmacy. This allows for additional safety features to include Allergy and duplicate medication checking. To access the medication order routine, highlight your patient and Click on Orders or press the “O” key.
The Review Patient’s Orders window will open.
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The Physicians Headers Tabs are set up according to the ’s individual preferences. The preferences are set up using the Preferences button.
The headings can be expanded to show all of the associated procedures by clicking on the + sign next to the header. The procedures can be collapsed by clicking on the – sign.
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Placing Medication Orders To order an individual medication, click on the Meds/Fluids button. For Verbal Orders, the does need to enter correct ordering provider and the Ordering Source. It will help if the provider is assigned to the pt in the Rm/Staff routine. This will bring the providers name to this screen automatically.
After entering past this prompt you will be taken to the Provider’s favorites if they have any set up. Otherwise you will see the Full Formulary.
Notice the Full Formulary is highlighted along with Medications. For example, begin typing in Motrin. Each letter you type will filter the search. Here you can see the Motrin with the (ED Stock). This is the one you want. The Choices with (ED Stock) or * on the medications are in the ED Pyxis. If you choose one w/o (ED Stock) or * there is a possibility it will not be available in the ED Pyxis. You would want to call Pharmacy so they can bring this med down.
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Now you can choose how you would like this med istered, for now will choose PO.
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Now you have the option to choose the dose. In this example we will choose 400 MG.
Now you will get all the strings associated to this dose. To select, highlight and click done or enter. You will be taken back to the All Medication page where you can start the process over.
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If you do not want any more meds click done. This will take you back to the Review Pt order screen.
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NOTE: The order has not been completed yet. You have to submit and file the order to complete the process. At this point you have several choices. You can Undo, Place more orders, go into an order set, add non-medication orders or, if done, you can submit the order. To submit, all you need to do is click the submit button. This will take you to a review screen.
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At this point you could click cancel and make changes if needed. Otherwise click OK to file the order. Now you can see the order has been filed.
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Now let’s look at the tracker.
The Medication indicator acts just like the Treatment indicator. It will be RED when there are Medication orders that have not been completed. This will turn to a RED Reverse Highlight if not completed w/in 60 minutes. The MED indicator will change to GREEN when all scheduled meds are given. PRN meds will show as a black PRN. Being the med is “as needed” it will not change colors. Reverse Highlight Purple means a reassessment is overdue. Before we go into the eMAR charting, let’s look at some other functions of medication ordering.
Editing Orders While in the string selection you can click on the drop down arrow to change any part of the order. To change the dose, click on the drop down next to the Dose section.
Now you can select the 50 MG or Other to edit the dose.
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Here I clicked “other”, changed the dose to 33 and added some free text dose instructions.
Now you can see the changes I made. The bubble indicates I have some Dose instructions. When done you can submit as per the directions above.
Special Instructions Special instructions can be placed on orders when the strings are built. They can also be added on the fly. While in the String Selection screen, click on the Inst drop down. This will give you a free text box.
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When done click OK. You will see the instructions as a bubble on the review order screen.
PRN medications Some Medication strings are pre-built as a PRN. You can also change a med to PRN as needed. To do this simply click on the PRN dropdown.
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After choosing “YES” you will want to select the PRN reason. If there is no PRN reason you can free text the reason. Then click done.
Now you can see the PRN and PAIN for the reason. Now you can submit the order. There is a separate indicator for PRN’s, which will not change color.
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Weight based dosing Some medications are set up for weight based dosing. Motrin and Tylenol are good examples of this. After selecting the medication you will se a string with the dose of MG/KG
Here the 10 MG/KG dose has been selected. Now click done or hit enter. You will see the following:
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If the Weight in the Vital Sign screen has been completed, you will see the Weight automatically come over. On the example above the system has automatically calculated the dose for this 70 KG pt at a 10MG/KG dose.
If you do not like that dose simply click in the box and manually change it. Being it will be impossible to give exactly 703 mg I will decrease this to 600 and file.
Now you can see the new order of 600 MG Motrin suspension. Now all you need to do is submit the order.
Home Packs Home packs are defined by a (Prepack) Next to the med. You can type Prepack to see all the available Prepacks as well.
You will want to choose the home pack dose and string when they come up.
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Now you can continue and submit the home pack and document on the eMAR.
Allergy Checking One of the biggest advantages of using medication ordering is patient safety. Currently the nursing staff is filing all allergies as coded. The medication ordering system in OE can now evaluate these allergies and notify you if there are any interactions. In the example below an order has been placed for a medication that the patient has allergies to.
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At this point you have several options. You can Override this allergy and order the medication, you can cancel and start over or you can replace the order with another. If you click on override you will get a drop down that you can select a response from.
After selecting the response you want it will take you to the string selection page. Confirming Allergies at each visit is very important. If you do not do this, the ordering provider will get an extra pop-up. Confirming allergies at every visit is also part of Meaningful Use.
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Reflex Orders Some orders have other orders attached. These are called reflex orders. One example of this would be Moderate Sedation. Let’s take a look at the Sedation order. To order sedation simply type in “MOD” for Moderate Sedation.
After selecting the Moderate Sedation Order and clicking done you will get the following:
After clicking OK you will be taken to the Review patient Order screen. Notice there are 2 new orders.
Now you can submit and see all 3 sedation screens under the treatment header in the Trg/Doc section and the NUR indicator will turn back to RED.
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Section 16: Electronic Medication istration Recored (eMAR) Now that Medications are interfaced with pharmacy you will be documenting medications via the eMAR. Accessing the eMAR: You will access the eMAR Desktop from the Tracker. You can either click on the MED or PRN indicator or highlight the patient and click on the eMAR button.
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The Header:
The Header: Pt info, Info, Location, Status, Allergy
Below the acct and unit number are the wt and height. The weight is pulled from the Vital Sign screen in EDM. When you click on this a box expands to give you detailed information including Wt in pounds and kg and BSA.
Pop up box
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The last line on the bottom of the header is the Allergy and AdvReac fields. If you click on either one of these it will open an information box.
Additional information available
The Medication Cell: The Medication Cell area has many features that give you the ability to view information easily, sort the data for individualized work preferences, and monitor your medications. The right hand column (toolbar) can be used to check all medications. This will help when you want to document the istration of multiple medications at one time. Simply click on the green check with the “all” under it to check all medications. You can also click on the check mark just above the other check marks to check all. If you want to uncheck one of them simply click on the check next to the med and it will be removed.
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Click either of these locations to check all
Below the patient;s allergies in the blue box on the left is the medication order ‘Start’ and ‘Stop’ times. For the ED all orders will generally be STAT or PRN. For the STAT orders you will see the stop time as one minute after the start time. The system then shows the order as DC’d.
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Please do not confuse this with a canceled order. If an order is cancelled it will be removed from the eMAR.
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Below we can see the difference between the STAT and PRN orders. The Acetaminophen is STAT. You can see the start and stop times along with the DC’d verbiage. The Zofran is PRN so it will remain active for the entire visit.
After the stat medication has been istered it will fall to the bottom of the eMAR, turn yellow and remain there for 2 hrs. This way if you need to document anything after you gave the med you can do so w/o having to bring the med back to the eMAR. You can adjust this time in the preferences if needed.
Sorting Features of the Medication Cell: To assist the nurse in performing the documentation of istering medications, you have the ability to sort your work area on the Desktop by clicking on the column headers.
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Clicking on the icons will bring you to the screen that each feature s. The “pencil to paper”
is the CDS (Customer Defined Screen) icon. When the medication is highlighted
blue (showing which medication is featured in each function) and a clicks on this icon in the medication cell, it will show the attached Customer Defined Screens (i.e. BP queries on Lisinoprol). At this point these pop up boxes are for information only, you enter that information during the actual process of giving the medication. Below is an example from a facility where they use a CDS for educating the patient on Digoxin. When viewing the pop ups from the icon, they are view only at this point but become fields to document on when scanning/istering the medication in the system.
The next icon over is the two pencils
, this is the icon for co-signer required on a specific
medication. When the co-signer actually signs as a co-signer, it will occur when you file the medications and a box will pop up that has the entry for the co-signers mnemonic and after hitting enter, will bring up the box to complete the electronic signature of the cosigner. (This will be illustrated later).
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The next icon is the Criteria, Label Comment and Special Instructions icon
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which
shows information from the pharmacy or the provider as to parameters he/she wants the medication given under.
When the clicks on the icon it will bring up specific information entered by the provider. This will not pop up when you ister the medication but is always available as information to the . You can see this same information when you review the history of the medication in the ‘Submit’ area.
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Medication Schedule Columns: Immediately to the right of the medication area is the column for the schedule of each medication. It has a green field to distinguish it from the other columns with the schedules next to it and does not move. PRNs, Stat, and One time do not have a schedule so for those medications nothing is showing (See Below). The ED typically only uses PRN and STAT so you will not see information in the Scheduled Time column.
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Below you will see the red background on the 1154 dose of Benadryl. This indicates the medication is overdue. The green background on the Tylenol indicates the medication is w/in the timeframe to be given. After the medication has been istered this will change to a gray reverse highlight.
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The Action Buttons at the Bottom of the eMAR Desktop: Once you are to the point of performing an action against the medication profile, you have the buttons at the bottom of the eMAR Desktop that have distinct functions and uses. The document button is used to document any checked medications. You can click on the istration time located next to the Sched Time column, or as noted above you can check all meds and then click on the document button to complete the documentation process. In the below example you can click in the check box next to the med and then the “Document” button to document on that single med:
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As seen here, the istration Queries popped up for Documentation, fill out the appropriate and enter through the screen.
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Once you finish the istration Queries screen, the remaining screen gives you the ability to select “Non-Scheduled”, “Scheduled” (with a drop down box to select the correct time and date), “Given”, “Not Given”, the “istration” time and date which can be changed to reflect a different time given today, the “Dose”, “Units”, “” mnemonic, and a “Text” drop down where you can click on and enter a note with the of just this medication.
Buttons at the bottom allow you to “Document” what you have changed on this pop up box or “Cancel” documenting here.
The next button “Ack” that resides next to the Document button takes you into the Acknowledgement area.
The next button is the “Preferences” button. This gives you the ability to make changes to your eMAR view.
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eMAR reports is just what is states, they can be placed on the button or auto printed (these are Meditech standard when seen here).
The “Change Order” button allows you to “Change Order”, “D/C Order”, or “Edit Orders” depending on your access level
Lastly, the “Submit” button. Use this button after you have documented your meds and are ready to finalize the process.
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Here we are at the point of decisions and choices. On the left we can unselect any medication that we decide we don’t want to document on. The other point is looking at all the information, making sure you are filing the right time and dates, using the edit button to make changes on anything you have documented on up to this point. After saving you will need to put your in.
Once you have determined you are ready to file the medication you have the following options: 1. “Return to eMAR” button does just that; it returns me to the eMAR to do additional documentation. If I don’t return but exit the eMAR I lose everything as if I never entered the eMAR. 2. “Save and Exit” will file the medications I have and return me to the Tracker. 3. “Save and Recompile” will file the medications and return me to the eMAR.
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This is what the eMAR will look like after you have documented and saved the medications.
Anytime a medication has been given it will be gray numbers on a white background. The
next to the Tylenol is the reassessment indictor. By clicking on the icon you will
get a pop up like this if the reassessment isn’t due:
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You can chose to document anyway, or what until the reassessment time (usually 30 minutes) arrives. This particular reassessment documentation screen looks like this:
EDM Here is what the medications look like on the patient summary:
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The Medication History: Every aspect of the process of documenting in the Desktop eMAR is saved and available to view by any . Everything from when the order was placed, to documentation with a co-signer. One area to see more detail is by clicking in the ‘Ack’ area as seen below:
After clicking in the “ACK” area or by clicking “ACK” button next to Document at the bottom left of the screen you will be presented with this Review Order screen:
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You will note there is a difference of the areas seen of dark blue to light blue, dark blue is the area being viewed. By selecting a different area header above, say ‘istrations’ we see all the information just about istering the medication show up (see below).
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The “History” button shows all the activity of the order from acknowledged, interaction checking, and documentation of the medication. There is one view, which will show it all in one place and that is the “Print Order” button.
When you click on this button a box will show to where you wish to print this, if you type in ‘VIEW’ or “PREVIEW in capital letters it will load all the information contained into this area and you just scroll down to what documentation you wish to see. Here we see the actual istration of the medication that includes the CDS for the B/P. If you were to look at PCI that B/P would be there as well.
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Section 17: Changing Chief Complaint Now let’s change the chief complaint. This will also change the assessments on the Triage/Documentation screen to allow for further charting on a new chief complaint (any assessments documented and filed will not be deleted). Click on the Chief Complaint on the Private Tracker or select the edit button next to the chief complaint on the Triage/Documentation screen.
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Hit F9 for lookup or go to private tracker screen and click on the chief complaint of the patient you are charting on. This will bring up the new complaint box and you can do F9 lookup.
When you find the new complain select it. An update chief complaint screen will appear, click yes.
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Section 18: Changing Status Events Status Events are how we track patient flow.
To manually change a Status Event, use the mouse to click on the current Status Event which is below the chief complaint on the Private Tracker. This will bring up the Update Status Event Screen.
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Now type in the mnemonic of the status event you want, for example, IR = “in radiology”. You can also use F9 to bring up a list of status events and select from that menu.
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Select the correct Status Event and file.
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Section 19: Departure and Discharge Documentation To complete the DC Disposition screen highlight your patient and click Trg/Doc then click on DC Disposition. Enter “D” or on your keyboard, or click on the Documentation button.
Type “N” for now appropriate time.
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Your cursor will be blinking in a white box labeled “Pain/Comfort Reassessed?” hit Y or N, tab to Intensity and type 1 – 10, tab to D/C Vitals? type Y or N. If yes then fill in each vital sign box. Discharge Meds: is free text. Tab over to Pre-Pak # and fill in blank if patient was sent home with a Pre-Pak. If a prescription was call into a pharmacy tab to Rx called to box and type in appropriate free text. Click or tab to Discharge Status/ and hit F9 to look up or type in mnemonic. Tab to Discharged To/, Belongings-Valuables/, Aftercare Instructions/, and Discharged Via/. In each field hit F9 to look up appropriate response and click. If the patient is itted to hospital click in the Report To: field and type the name and title of the person you gave report to and tab over to time and fill in. The white boxes Equipment Used During Transfer? and Staff Present During
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Transfer/ you can use F9 and choose best response. Sedating Meds? Type Y or N and Transportation Provided By/ is an F9 look up. The Bottom white comment box is free text. When finished hit F12 to file. Next you want to depart the patient. From the tracker highlight the patient you want to depart, click Depart and press “D” or click on the Document button.
Review and confirm what the physician has entered into the screen and file.
When you are sure the information is correct hit the ok and this will take you back to the Depart screen. Click on the Depart button.
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The patient is now discharge from the emergency department. Once the charting is complete you will print one encounter for Medical Records/Billing. To print the encounter click on the Summary button or double click the patient’s name,
the encounter will come up on the screen. Click the printer icon button and make sure the “print all” box is checked and print. This should then remove the patient from the Private Tracker to the Discharged Tracker.
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Section 20: ission Documentation When the patient is ready to be itted, you will want to fill out the DC Disposition screen just like you did on a patient being discharged from the emergency department with one exception. Fill out the box “report given to” and time report was given and hit F12 to file.
Make sure when you go to Depart the patient you confirm the physician has entered the patient is itted to the hospital as inpatient or observation.
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Section 21: Documenting on the Wrong Record If you accidentally chart on the wrong patient you can easily make corrections. Select the patient from the Private Tracker and click on Trg/Doc. Double click on the Assessment or Treatment that was charted wrong or click on the (+) to the left of the Assessment/Treatment title. This will expand the assessment or treatment menu.
Highlight the assessment or treatment you want to undo and click “undo” on the far right of the screen. You can also type “U”. Click on “yes” to file.
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Note, the assessment or treatment that has been undone will not be deleted from the record; it will turn gray to indicate this documentation has been modified.
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Section 22: Editing Records After you have filed an assessment or treatment on occasion you may need to add or change information that had been entered. You can only do this if you were the individual who charted on the patient in the first place. First, highlight the patient from the Private Tracker. Click on Trg/Doc, double click the Assessment or Treatment that was charted on. You may also click on the (+) to the left of the Assessment or Treatment and expand the menu. Highlight the Assessment or Treatment you want to edit and click “Edit/Amend” or hit “E” on your keyboard.
You may now make your changes and then hit F12 to file.
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You can now see the record has been edited.
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Section 23: Patients Accidentally Departed If you accidentally depart a patient from the tracker, or make the Status Event “Discharged” before all documentation is complete it can be undone. First you must back out to the EDM Main Menu.
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Click on Patient Routines and a pop up menu will appear, from the list click on “Update Status Event”.
EDM First type in the patient name and search for the correct patient.
You can see patient Tonka Truck is IN RAD.
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To change the status event click in the New Status Event box and hit F9. A menu of status events will appear, choose your new Status Event and click “OK”.
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Section 24: Clinical Review The “Review” button launches clinical review known as EPS or Extra PCI Database Source. “Review” allows you to review the latest patient data, for example, results, the patient summary, order history, PCI, and other visits. Nursing assessments can also be seen here. To launch Clinical Review simply click the “Review” button on the Integrated Desktop. If you would like to launch Clinical Review on a patient who is not on the tracker simply use the Magic Key menu by hitting shift and F12.
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When Clinical Review is launched you will see the patients’ demographics at the top of the screen. On the right of the screen highlighted in red is the Verb Strip, these buttons allow you to navigate through Clinical Review.
FYI: At the bottom left of the screen you have the option to ask for help email
, or use the web
, print
,
. You may also launch PCI or Order entry by clicking the buttons
on the bottom of the screen. If at anytime you want to return to the Private Tracker click Patient List on the bottom of the Verb Strip.
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“Pt Summary” shows general information on your patient. /Demographics are also available here. When clicked you will see the following screen:
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“Special ” gives access to s that Meditech has built to cover provider specialties. If labs have been resulted that are included in these s they will be available to view. After viewing a use the “Back” button to return to this screen. When the ALL LAB Results button is clicked in this screen an easy to read lab report is generated.
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“Order History” shows details on all the orders that have been placed on your patient. When clicked you will see the above screen:
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“Lab” shows recent lab results. When clicked you will see “lifetime Summary” this will show lab results from November 2008 to present. Data prior to this date is in PCI.
EDM Microbiology tab will launch microbiology results if the patient had this type of test done.
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Blood Bank and Pathology will generate reports if the patient had this type of testing done. If there are no results to be seen the button will be gray.
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The Medications button will generate a report which will allow you to see medications ordered for the patient, the dose, route, start and stop date, status, and when last istered.
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The Imaging tab will launch imaging reports, Other Reports tab will allow you to view many different kinds of reports, for example, dictations, and Notes History will allow you to see physician notes which have been filed.
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“Assessments” will show nursing documentation.
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“Other Menu” is a way of building a with I & O and meds or you can launch the Reconciled Medication screen.
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“Other Visits” allows access to data from other visits to the hospital this patient has had. Information will be available for the other buttons in this screen as tests are completed for those categories.
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Section 25: Patient Care Inquiry
Section 19: Patient Care Inquiry (PCI) Patient Care Inquiry (PCI), allows you to move into historical data on the selected patient. PCI provides access to history, lab, radiology, and other data that has been documented on this patient within our regional hospitals. PCI allows you to access the following information in a Patient’s Chart: Orders istrative Data Current and historical medications Hospital visits (w/abstracts) issions Information Laboratory, Microbiology, Anatomical Pathology, and Blood Bank Radiology Exams and Reports Recent Clinical Results Ancillary Dept. orders and results Three important tools help you navigate through PCI with minimal keystrokes: 1. Highlighter Bar 2. Arrow Keys 3. Control Key
Highlighter Bar- horizontal bar that highlights an entry on the screen . You move it up and down the list of entries using the arrow key. Arrow Keys- perform the following functions: *Move the highlighter bar up and down the list of entries. *Allow you to view the highlighted entry in more detail. *Allow you to return to the previous screen. Control Key-allows you to select multiple screen entries on which you want to execute a verb strip command. 1. Move the highlighter to the entry. 2. Press
(checkmark appears) 3. To select another entry, repeat steps 1&2.
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NOTE: For on-line documentation, simply hold down <Shift> and
at the same time. Press Shift+F8 (documentation key) to view instructions on how to answer a prompt. On a routine or dictionary screen: On a menu screen: Press Shift+F8 at a prompt for an Enter a routine number and press Explanation: Shift+F8 for: * on how to respond to a prompt * the purpose of a routine * of the prompt’s function * brief description of the screen To access PCI from the tracker, highlight the patient you want and type “P” or click on PCI with your mouse.
That will bring up the PCI screen.
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The PCI Identify Patient Menu After you select PCI from your Main Menu, the system displays the Identify Patient window, which lists several methods of identifying patients. Use the up and down arrows to move the highlight bar to what you want to select then right arrow to view your selection. The PCI Menu lists several methods of identifying a patient in the Identify Patient Window.
IDENTIFYING A PATIENT BY NAME, NUMBER
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IDENTIFYING A PATIENT BY SOUNDEX NAME:
This method of identifying patients enables you to identify all patients with a medical record whose name matches the criteria entered. This feature helps you locate a patient’s record in the event you are unsure of spelling.
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Viewing Data in PCI Once you have navigated to the correct patient you will be taken to the PCI Table of Contents screen. This screen provides you with different options use the up and down arrows and place the highlight bar on an entry to select. Right arrow to view selected entry. The Verb Strip shows the functions that may be performed on this screen.
PCI uses windows to display patient information in a logical, step-by- step manner, moving from general to detailed. The Table of Contents displays all information available for a patient. Once you identify which category you would like to know more about, the ensuing windows provide increasing levels of detail.
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To view data highlight what you want from the table of contents and right arrow to next screen.
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You will be taken to the summary window, choose what you want to view and right arrow over to next screen.
EDM You have now launched to the history screen, right arrow over to next screen.
You are now at the detail window and can view results.
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Split Screen Feature The split screen feature enables you to simultaneously view data from two different sources at any Summary or History Window. Clinical staff may find this useful when comparing two different laboratory results.
Click to print
Click full to return to full screen
After you have the summary or history window of one clinical result on your screen, enter an “S”. The Table of Contents window appears. Select the date source and nd
highlight the 2 item you wish to view. Press the right arrow key twice or after you right arrow in the table of contents screen enter “S” or click Split. To return to full screen type “F” or click Full.
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Printing and Other Verb Strip Functions Most of the reports in PCI are printed from the History window by selecting the verb command “P”. A pop up Box with “Print this history report” and “Print details of the highlighted item” will appear. Make your appropriate selection,
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The Bulletin Board is used as a communications tool between clinicians. Information entered into the Bulletin Board may be viewed by all clinical staff that accesses the patient.
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Clinical Highlights is a defined data source on the Table of Contents where you can group frequently viewed data on one screen for patients you specify. Entire data sources can be added or specific entries from the summary window can be added. This feature is and patient specific.
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Click to go over to next screen Patient Summary will allow you to quickly access the patient’s summary.
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Click to view reconciled medications
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Choose which query you would like to view and right arrow over to open Medication Recon screen.
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Viewing Discharge Instructions Scroll the highlight bar down to “Emergency Department Data” and right arrow key over to next screen.
EDM Highlight “Pt Instructions” and right arrow over to view.
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Appendix A (Chief Complaints)
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Appendix B (Assessments)
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Appendix C (Treatment Indicators)
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References A g g a b a o S t a c e y, S . A . ( 2 0 1 1 ) . E m e r g e n c y d e p a r t m e n t m a n a g e m e n t [Electronic mailing list message]. Retrieved from https://webmail.pullmanregional.org/owa/ In l an d No rt h wes t Heal t h S erv i ce (INHS ), In i t i als . (20 11 ). M edi t ech nursing training manual emergency department (edm). h t t p : / / w w w. i n h s . i n f o /
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Table of Contents SECTION 1
4
WHAT IS EMERGENCY DEPARTMENT MANAGEMENT SECTION 2
4-5
TRACKER REVIEW SECTION 3
5-6
EDM TOOLBAR SECTION 4
6-7
FUNCTION KEYS SECTION 5
7-10
INTEGRATED DESKTOP TRACKER BUTTONS SECTION 6
10-13
G INTO EDM SECTION 7
14-20
TRIAGE SECTION 8
21-25
VACCINE/MDRO/ALLERGIES SECTION 9
26-44
MEDICATION RECONCILIATION SECTION 10
45-46
VITAL SIGNS SECTION 11
47-48
PSYCHOSOCIAL SECTION 12
49-51
ASSIGN ROOM AND NURSE SECTION 13
52-53
CHARTING ASSESSMENTS SECTION 14 TREATMENT INDICATORS/INTERVENTIONS
54-64
EDM SECTION 15
65-83
MEDICATION ORDERING SECTION 16
83-104
ELECTRONIC MEDICATION ISTRATION RECORD (EMAR) SECTION 17
104-106
CHANGING CHIEF COMPLAINT SECTION 18
107-109
CHANGING STATUS EVENT SECTION 19
110-114
DEPARTURE AND DISCHARGE DOCUMENTATION SECTION 20
115-116
ISSION DOCUMENTATION SECTION 21
117-119
DOCUMENTING ON WRONG RECORD SECTION 22
120-121
EDITING RECORDS SECTION 23
122-125
PATIENT’S ACCIDENTALLY DEPARTED SECTION 24
126-139
CLINICAL REVIEW SECTION 25
140-160
PATIENT CARE INQUIRY (PCI) APPENDIX A
161-169
CHIEF COMPLAINTS APPENCIX B___________________________________________________________________________________170-171 ASSESSMENT LIST APPENDIX C___________________________________________________________________________________172-177 TREATMENT INDICATORS
3
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Emergency Department Management (EDM) Instructions Section 1: What is Emergency Department Management? EDM was implemented at Pullman Regional Hospital to improve patient care in the emergency department. This is accomplished by improving efficiency related to documentation. Greater efficiency can be accomplished by simplifying, streamlining, standardizing and enhancing the documentation process through computerization of the patient care record. Information flows easily within all setting of Pullman Regional Hospital and other facilities within the INHS network while maintaining patient privacy. Section 2: Tracker Review Prior to logging in you will be able to visualize the public tracker. After logging in you will visualize the private tracker. To quickly view the encounter, click on the patient’s name or click the Summary button. The encounter is a real time view of the patient’s progress in the emergency department. It will show everything that is current and done for the patient. You will see the patient’s name, age, chief complaint, priority, assigned nurse mnemonic, status event, time in department, results indicator area, integrated desktop, and tool bar. HELPFUL HINTS:
• To quickly view the encounter, click on the patient’s name. • To assign a room number, click on the room number located at the top left of the screen. • To change/update the chief complain, click on the chief complaint. • To change the status event, click on the status event. • To view lab, radiology, ultrasound, CT and etc., click on the results indicator area. • To to be the primary nurse, click on the button on the integrated desktop on the far right of the screen. • To access PCI, click on the PCI button on the integrated desktop.
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• To access Clinical Review click the Review button on the integrated desktop. • To chart Treatments click the NUR button in the results indicator area. • Quickly access the electronic medical record by clicking the eMAR button on the integrated desktop.
The Private Tracker
Section 3: EDM Tool Bar
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The EDM tool bar is found on the far right of the screen (highlighted in red) and works as follows: • • • • • • • • • •
Green check = OK or file Red “X” = exits you out of the current screen or pop-up Question mark = help Binoculars = look-up patient information of certain screens Green star/red X = session management, magic key menu Tools = access to a calculator Blue flower = special function key Green check all = checks all items in order sets in physician order management Blue arrows = up, down, back and forth in one field Green arrows = page up and page down
Section 4: Function Keys •
F12 = OK/file, exits and files entries
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Shift + F12 = hot key menu/magic menu F11 = exits and does not file or save entries F10 = line feeds to erase current field F9 = lookup key for list of choices F8 = page down ( same as green arrow down) Shift +F8 = access on-line documentation F7 = page up (same as green arrow up) F6 = takes you back to the previous field F5 = auto fill F4 = Gives you access to “canned text”
SECTION 5: Integrated Desktop Tracker Buttons Meditech’s Emergency Department Management (EDM) application includes a Patient Tracker Integrated Desktop. This application gives staff a central point of data entry for documenting the daily treatment of patients and for managing the flow of patients through the system. The EDM system, which tracks patient test results, medication orders, and vital signs, serves as a communication tool between physicians, nurses, and the departments with which the Emergency Department staff interacts. Most of your documentation will be done from one of these tracker buttons. The integrated desktop is highlighted in red below:
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TRACKER BUTTONS (INTEGRATED DESKTOP) •
• • • • • •
• • • • •
Summary: Enables you to view or print out the patient’s complete EDM record for the visit. Can also click on the patient’s name or highlight the patient’s name and right arrow. Ret: Not used Room/Staff (Rm/Staff): Let’s you assign a room and staff to a patient. Usually done by charge nurse in triage. Sign up: assigns you to the patient. Triage/Document (Trg/Doc): This will take you to the triage/documentation screen where assessments and interventions are documented. Reconcile: Takes you to the Medication Reconciliation screen. Advanced Status Event (Adv St Ev): Gives you a limited selection of status events to change to. You may also change the status event by clicking directly on it. By using the method you will get the full list of events. Pt Notes: Allows for general patient notes to be added to your documentation. Orders and Order Summary: Here you can place and view orders. eMAR: Takes you to the electronic medical record. Review: Takes you to Clinical Review PCI: Allows you to view specific patient care information.
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•
9
Depart: This is where discharge functions are performed. If the patient is going home you will need to hit depart. If the patient is itted you will depart them and update the status event. Comment: Allows you to type in a comment. You can do this by clicking the Comment tab or clicking under the HM in the results indicator area. When a comment is left an * will appear. Just click the * to view. To delete the comment open and delete then file. See screen shots below:
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• •
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Trackers: Allows you to view current patients and discharged patients. Forms: Use to print medication reconciliation form for itted patients.
Section 6: g Into EDM There are two ways to sign in to EDM. From the computer desktop go to the icon “HCIS” and double click on it. You will see a screen labeled MIS Directories. Choose #1 which is “live”, and this should take you to a screen.
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Enter your ID and .
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You will be taken to the EDM Main Menu. From here you choose where you want to go. To reach the Private Tracker click on All Patients.
This will take you to the private tracker and you are ready to begin charting. If the public tracker is already on the computer screen, simply hit right Ctrl key and proceed to with name and . At this point you are ready to chart on your patient. Be sure you are charting on the correct patient. Click on the patient you want to chart on and it will highlight blue.
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Helpful hints for charting see highlighted areas below: • • • •
/ = F9 lookup (may not use free text). : = Can use free text. ? = Yes or no question. All you have to do is type Y or N. + = There is text in the background. To access hit Shift + F8.
Examples in red below:
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Section 7: Triage The first thing to be done in triage is to assign a chief complaint. To begin, select the correct patient and click on the Trg/Doc button from the private tracker. Click the “Edit” button next to the chief complaint field near the top of the screen.
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Hit F9 and all the accepted chief complaints come up. Choose which complaint is appropriate for the patient. You may also type in the mnemonic. For a complete list of chief complaints see appendix A.
Now you are ready to go to the triage screen. Under Assessments click the “+” on the left and then on triage, go over to the Integrated Desktop on the right of the screen and click Document or just type “D” on the keyboard. Your cursor will go to the Date, just type “T” for today. Next, the cursor will move to the time box, type “N” for now.
You are now ready to begin the triage assessment.
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Start with answering the questions at the top of the screen (exposure, and interpreter) if applicable. Arrived By/ and With/ are F9 look-up or you may type in the correct mnemonic. Next is your note in the Objective/Subjective field. This is free text, when finished hit F12 to file. After you hit F12 and file your Objective/Subjective History your cursor will be blinking in the Medical/Surgical Hx area. Fill out Medical/Surgical Hx; this is a free text field. You must hit enter F12 to move onto the next line. Click on Last Tetanus and record the year the last tetanus was given. Hit enter and tab over to Immunizations Current and type “Y” or “N”. Hit enter to Last Menstrual Period and type in date. Tab through and fill out number of pregnancies, live births, and abortions. Fill in Primary Care Physician and use F9 to look up the correct provider. Enter or tab over to weight and enter in LB, hit enter until you reach height and fill in each box. Enter the patient’s primary
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physician and click “OK”. Now you are back at the Trg/Doc screen. Near the bottom of the screen is Status Event (TRG), click this button and hit Document.
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Choose your new status event and Hit Ok or F12 to file.
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Lastly assign a priority. Click the Priority button at the bottom of the private tracker screen and hit Document, a white box will appear, hit F9 to look up and assign the appropriate priority from 1 – 5.
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Section 8: Vaccine/MDRO/Allergies
Now let’s chart the patient’s vaccines, MRSA, VRE, and allergies. Highlight Vaccine/MDRO/Allergies and hit “D” or click the Document button. Type “N” for now and this is what the screen will look like.
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Type “Y” in the Update Allergies white box and you will be taken to the Allergy Management screen as seen here.
Highlight each allergy listed and with patient and click confirm on the Verb Strip. If a new allergy needs to be entered click “New” on right hand of the screen.
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Type in the allergy and a list will appear in large white box. Click on correct allergy and select severity. At the bottom of the screen there is a white box labeled “Reaction”, hit the down arrow and find appropriate reaction and click. Make sure the verified box is checked at bottom right of the screen and file and you will be taken back to the Vaccine/MDRO screen.
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When you have finished entering the patients allergies you will be rerouted back to the Vaccine/MDRO screen. The cursor will be automatically be blinking in the Drug Resistant Organism History Reviewed? Box. Type “Y” and enter to fill in blanks. If the Patient has a documented history of MRSA the fields associated with it will be auto populated. Next the cursor will go to the Have you had the influenza (Flu) Vaccine this season/, type “Y” or “N”. Do the same for the pneumonia box. Hit enter and fill in the white boxes as applicable. When finished click “OK”. You will then be taken to the HOME MEDICATION HISTORY screen as seen below. The cursor will be blinking next to the “Y” in the Update medication list? box, hit enter and you will be taken to Medication Reconciliation.
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Section 9: Medication Reconciliation
The Medication Reconciliation screen will come up two ways. After you have finished entering allergies in triage and click yes in the HOME MEDICATION SCREEN or when you click the blue header in the Trg/Doc screen titled Active Prescriptions/Reported Meds. You will see the patients name, DOB, and unit number at the top of the screen. Below the name will be documented allergies. In the middle of the screen will be the main headers: Home Meds and Prescriptions or Discontinued Home Meds if applicable. The large white box will have no headers if the patient
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This will open the update med list screen.
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Begin typing the home medication here. This is a type-ahead functionality and the search will narrow down the choices of medications by the more letters that are typed. The begins in their Favorite List but the system will automatically go to “Go to All Meds” if the medication is not found. As you type medications from a database of 33,000 will come up. For example, if you type (tyl) all forms of Tylenol will appear. In this example, tyl has been entered, narrowing the search down to medications beginning with these three letters. Highlight by clicking with your mouse or using your arrow up/down key to select the desired medication. Click on the Select button at the bottom of the screen when finished.
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This will take you to the screen where you can manually fill in Dose, Units, Route, and Frequency.
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You may also auto populate the correct Dose, Unit, and Route fields by clicking the blue string. Click done when finished.
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On this same screen instructions can be typed in. For example, patients who are taking Coumadin on Monday, Wednesday, and Friday can have that put into this section.
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The box below Instructions is Comments. This is where you want to enter the indication for the medication. Click on the down arrow
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A pop up box will appear, choose #2 Indication for med.
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A list of indications will appear, choose what is appropriate for your patient.
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The indication will auto populate a white box when you click what you want, then click OK.
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If the entries are correct, select Done.
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After you have clicked on Done, you will be taken back to the Last Taken screen where you can enter the date and time when the patient last took their medications.
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The Monograph will appear in a pop-up box as seen below.
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You have now launched the Last Taken screen.
Click on the correct date on the calendar and enter the time the patient took their mediation. Only enter the dose if it different than what is reported in the medication reconciliation screen. Click “OK” when finished. You will now see you medication under the header Home Meds and Prescriptions. Highlight the review button if all the information is correct and click Submit on the Verb Strip, you will be taken to the Medication Reconciliation Summary screen. If your information is correct click “OK”. If you need to make changes you can click cancel and start over.
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Finally click the Return button and you will be taken back to the Vaccine/MDRO HOME MEDICATION SCREEN.
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Fill in the patient’s pharmacy and disposition with free text. Use the F9 key and choose what is appropriate for the Medication history box. Type “Y” or “N” in the ASA, NSAIDS, anticoagulants and herbal products fields. You may also free text in the large white box after the remedies. Enter down to the Home Med Hx field and hit F9 and choose the appropriate response. Type “Y” or “N” for pharmacy consult and a reason if need be. You may type additional comments in the white comment field at the bottom of the screen. When finished click “OK” and you will be taken to the Trg/Doc screen. Click on ALLERGY BAND PRINTING and type “Y”. Your allergy band will print in triage. Be sure to apply to patient.
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The screen shot below shows what the Private Tracker results indicator area will look like when you have completed documenting home medications: The red HM indicates that someone verified allergies and MDROs but did not complete the meds and checked “nursing f/u” in the drop down menu. The green HM indicates that both the allergies/MDRO and home medication have been completed and the nurse marked “completed” in the drop down menu. If the area is blank neither the allergies/MDRO or home medication screens have been completed.
HM = Nursing F/U selected on Home Med Hx Status HM = Complete selected on Home Med Hx Status Blank = MDRO/Vaccine Assessment not filed
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Section 10: Vital Signs Highlight vital signs and hit “D” or click on the Document button. Type “N” for now or type in the time the vital were assessed.
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Type in results for Temp, Pulse, Resp., BP etc. For the method, rhythm, site etc. use the F9 lookups to select appropriate response or type the mnemonic. Type in Capillary Refill, press enter. Fill in O2 sat and press enter. Type in LPM of O2 and press enter, O2 type/ can use F9 lookup and choose appropriate response. Type “Y” or “N” for cardiac monitor and orthostatic BP. If yes for orthostatic BP a pop up screen will appear, fill in each field file with F12 and return to VS screen. In the Pain? Box type “Y” or “N” and press enter. Next type in intensity from 1 – 10 and press enter. There is a “+” outside the Intensity and Cardiac Monitor box which means there is hidden text, to access hit F8. Location: is free text. In the field for Pain Quality/: use the F9 function key and choose appropriate response. Comment: is free text. Hit F12 to file.
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Section 11: Psychosocial Click on Psychosocial and hit “D” or click on Document. Type “N” for now.
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Use F9 to look up and fill in Functional Impairment, Factors Affecting Ability to Learn, and Living Arrangements. Do you feel concerned for your safety is a required field. Type “Y” or “N”. Enter down to information obtained from: and fill in appropriate box with a “Y” or “N”. Comment field at the bottom of the screen is free text. This may be used if a person does not feel safe and you need to explain. Click OK or F12 to file. Select the red “X” or hit F11 to exit this screen and return to the tracker.
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Section 12: Assign Room and Nurse With the patient highlighted from the private tracker, click on Rm/Staff button on the right side of the screen in the Integrated Desktop, click in the room box type in a room number or choose from list with F9.
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If the primary nurse is known their name can be put in at this time by typing in his/her mnemonic in the nurse box. Hit F12 to file and save. If the charge or triage nurse has not already assigned the patient to you the first step is to for the patient. To do this, make sure the patient you want is highlighted on the private tracker and then click the button on the right hand of the screen on the Integrated Desktop.
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Section 13: Charting Assessments The assessments are linked to the patient’s Chief Complaint. For example, a patient with Irregular Heart Beat will automatically generate Cardiac and Respiratory assessments. As a reminder, to chart an assessment, there are a few things to look at. Some of the fields are free text, designated by a “ : “. Others are look up menus designated by “ / “ hit the F9 key and this is where you choose from a list (or type the mnemonic). When you see “ ? “ you type “Y” or “N” for yes or no.
Click on the assessment then hit Document on the integrated desktop or type “D”. Furthermore, you may add additional assessments or treatments for your patient by clicking the assessment or treatment buttons. Next type “D” or click Document. A white box will appear, hit
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F9 or type the mnemonic to add assessment or treatment. From this list choose the one you want to complete. Hit F12 to file. For a complete list of assessments please see appendix B.
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Section 14: Treatments Indicators/Interventions With Treatment Indicators it is very important to place orders on the patient before documenting. This will bring the documentation to the Trg/Doc screen. Place orders through Physician Order Management (POM) by highlighting your patient and clicking the Orders button on the EDM Tracker and then in POM. When order sets are used click on the Order Sets button instead. Here is an example of Treatments/Interventions in POM. Most of the orders have been in place for a while, but some new treatments will now exist. Notice the Category is EMERGENCY DEPARTMENT and there is an “ER” or “ED” at the end of each order.
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Now let’s chart some treatment indicators. This would be interventions we do for our patient’s, for example, IV insertion, IV removal, foley catheters, and ice packs. The physician will enter orders which then will generate treatment indicators for the nurse. When new orders are placed the “NUR” indicator on the Private Tracker will turn red alerting the nurse there are new treatments ordered.
The nurse can either click on the red “NUR” or click Trg/Doc to launch the Patient Triage/Documentation screen to view and chart his or hers treatments.
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The new treatment indicator will be highlighted in green under the blue “Treatments” header. Click the green treatment indicator and then document to begin charting. For example, click the green Foley Catheter and click Document.
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When finished with your charting click “OK”.
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The treatment indicator will now turn black and a “+” will appear in the left column letting the nurse know the treatment is complete.
When all the treatments have been documented the NUR indicator will change to Green. One exception is the IV DC. It will not trigger the indicator to change color since it will not get documented until the end of the visit.
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Patient Summary View:
Documented interventions will show on the Patient Summary in the Treatment section.
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You may want to add treatments. To chart on a treatment that is not generated by the physician orders, you can add an additional treatment from the treatment list, for example, bedside commode. To do this, arrow down to, or click on Treatments so the blue treatments header is highlighted. Hit “D” or click Document button to add treatment.
From here a white box will appear type in the mnemonic of the treatment or hit F9 to lookup. Once the list pops up, select the treatment you want to chart on.
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Select number 9 Bedside Commode and you will automatically start charting.
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Click “OK” when finished and you will see the Bedside Commode charting is under the treatments section in black with the “+” to the left of the column
You use the same process to add assessments. You will notice when assessments are completed and filed they will have a “+” next to them on the left side of the screen just like the treatments. You can click on the (+) to expand the treatments or assessments. For a complete list of treatments and interventions see appendix C and D.
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Section 15: Medication Ordering Medication ordering allows us to interface the ordering process with Pharmacy. This allows for additional safety features to include Allergy and duplicate medication checking. To access the medication order routine, highlight your patient and Click on Orders or press the “O” key.
The Review Patient’s Orders window will open.
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The Physicians Headers Tabs are set up according to the ’s individual preferences. The preferences are set up using the Preferences button.
The headings can be expanded to show all of the associated procedures by clicking on the + sign next to the header. The procedures can be collapsed by clicking on the – sign.
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Placing Medication Orders To order an individual medication, click on the Meds/Fluids button. For Verbal Orders, the does need to enter correct ordering provider and the Ordering Source. It will help if the provider is assigned to the pt in the Rm/Staff routine. This will bring the providers name to this screen automatically.
After entering past this prompt you will be taken to the Provider’s favorites if they have any set up. Otherwise you will see the Full Formulary.
Notice the Full Formulary is highlighted along with Medications. For example, begin typing in Motrin. Each letter you type will filter the search. Here you can see the Motrin with the (ED Stock). This is the one you want. The Choices with (ED Stock) or * on the medications are in the ED Pyxis. If you choose one w/o (ED Stock) or * there is a possibility it will not be available in the ED Pyxis. You would want to call Pharmacy so they can bring this med down.
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Now you can choose how you would like this med istered, for now will choose PO.
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Now you have the option to choose the dose. In this example we will choose 400 MG.
Now you will get all the strings associated to this dose. To select, highlight and click done or enter. You will be taken back to the All Medication page where you can start the process over.
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If you do not want any more meds click done. This will take you back to the Review Pt order screen.
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NOTE: The order has not been completed yet. You have to submit and file the order to complete the process. At this point you have several choices. You can Undo, Place more orders, go into an order set, add non-medication orders or, if done, you can submit the order. To submit, all you need to do is click the submit button. This will take you to a review screen.
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At this point you could click cancel and make changes if needed. Otherwise click OK to file the order. Now you can see the order has been filed.
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Now let’s look at the tracker.
The Medication indicator acts just like the Treatment indicator. It will be RED when there are Medication orders that have not been completed. This will turn to a RED Reverse Highlight if not completed w/in 60 minutes. The MED indicator will change to GREEN when all scheduled meds are given. PRN meds will show as a black PRN. Being the med is “as needed” it will not change colors. Reverse Highlight Purple means a reassessment is overdue. Before we go into the eMAR charting, let’s look at some other functions of medication ordering.
Editing Orders While in the string selection you can click on the drop down arrow to change any part of the order. To change the dose, click on the drop down next to the Dose section.
Now you can select the 50 MG or Other to edit the dose.
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Here I clicked “other”, changed the dose to 33 and added some free text dose instructions.
Now you can see the changes I made. The bubble indicates I have some Dose instructions. When done you can submit as per the directions above.
Special Instructions Special instructions can be placed on orders when the strings are built. They can also be added on the fly. While in the String Selection screen, click on the Inst drop down. This will give you a free text box.
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When done click OK. You will see the instructions as a bubble on the review order screen.
PRN medications Some Medication strings are pre-built as a PRN. You can also change a med to PRN as needed. To do this simply click on the PRN dropdown.
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After choosing “YES” you will want to select the PRN reason. If there is no PRN reason you can free text the reason. Then click done.
Now you can see the PRN and PAIN for the reason. Now you can submit the order. There is a separate indicator for PRN’s, which will not change color.
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Weight based dosing Some medications are set up for weight based dosing. Motrin and Tylenol are good examples of this. After selecting the medication you will se a string with the dose of MG/KG
Here the 10 MG/KG dose has been selected. Now click done or hit enter. You will see the following:
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If the Weight in the Vital Sign screen has been completed, you will see the Weight automatically come over. On the example above the system has automatically calculated the dose for this 70 KG pt at a 10MG/KG dose.
If you do not like that dose simply click in the box and manually change it. Being it will be impossible to give exactly 703 mg I will decrease this to 600 and file.
Now you can see the new order of 600 MG Motrin suspension. Now all you need to do is submit the order.
Home Packs Home packs are defined by a (Prepack) Next to the med. You can type Prepack to see all the available Prepacks as well.
You will want to choose the home pack dose and string when they come up.
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Now you can continue and submit the home pack and document on the eMAR.
Allergy Checking One of the biggest advantages of using medication ordering is patient safety. Currently the nursing staff is filing all allergies as coded. The medication ordering system in OE can now evaluate these allergies and notify you if there are any interactions. In the example below an order has been placed for a medication that the patient has allergies to.
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At this point you have several options. You can Override this allergy and order the medication, you can cancel and start over or you can replace the order with another. If you click on override you will get a drop down that you can select a response from.
After selecting the response you want it will take you to the string selection page. Confirming Allergies at each visit is very important. If you do not do this, the ordering provider will get an extra pop-up. Confirming allergies at every visit is also part of Meaningful Use.
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Reflex Orders Some orders have other orders attached. These are called reflex orders. One example of this would be Moderate Sedation. Let’s take a look at the Sedation order. To order sedation simply type in “MOD” for Moderate Sedation.
After selecting the Moderate Sedation Order and clicking done you will get the following:
After clicking OK you will be taken to the Review patient Order screen. Notice there are 2 new orders.
Now you can submit and see all 3 sedation screens under the treatment header in the Trg/Doc section and the NUR indicator will turn back to RED.
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Section 16: Electronic Medication istration Recored (eMAR) Now that Medications are interfaced with pharmacy you will be documenting medications via the eMAR. Accessing the eMAR: You will access the eMAR Desktop from the Tracker. You can either click on the MED or PRN indicator or highlight the patient and click on the eMAR button.
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The Header:
The Header: Pt info, Info, Location, Status, Allergy
Below the acct and unit number are the wt and height. The weight is pulled from the Vital Sign screen in EDM. When you click on this a box expands to give you detailed information including Wt in pounds and kg and BSA.
Pop up box
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The last line on the bottom of the header is the Allergy and AdvReac fields. If you click on either one of these it will open an information box.
Additional information available
The Medication Cell: The Medication Cell area has many features that give you the ability to view information easily, sort the data for individualized work preferences, and monitor your medications. The right hand column (toolbar) can be used to check all medications. This will help when you want to document the istration of multiple medications at one time. Simply click on the green check with the “all” under it to check all medications. You can also click on the check mark just above the other check marks to check all. If you want to uncheck one of them simply click on the check next to the med and it will be removed.
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Click either of these locations to check all
Below the patient;s allergies in the blue box on the left is the medication order ‘Start’ and ‘Stop’ times. For the ED all orders will generally be STAT or PRN. For the STAT orders you will see the stop time as one minute after the start time. The system then shows the order as DC’d.
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Please do not confuse this with a canceled order. If an order is cancelled it will be removed from the eMAR.
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Below we can see the difference between the STAT and PRN orders. The Acetaminophen is STAT. You can see the start and stop times along with the DC’d verbiage. The Zofran is PRN so it will remain active for the entire visit.
After the stat medication has been istered it will fall to the bottom of the eMAR, turn yellow and remain there for 2 hrs. This way if you need to document anything after you gave the med you can do so w/o having to bring the med back to the eMAR. You can adjust this time in the preferences if needed.
Sorting Features of the Medication Cell: To assist the nurse in performing the documentation of istering medications, you have the ability to sort your work area on the Desktop by clicking on the column headers.
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Clicking on the icons will bring you to the screen that each feature s. The “pencil to paper”
is the CDS (Customer Defined Screen) icon. When the medication is highlighted
blue (showing which medication is featured in each function) and a clicks on this icon in the medication cell, it will show the attached Customer Defined Screens (i.e. BP queries on Lisinoprol). At this point these pop up boxes are for information only, you enter that information during the actual process of giving the medication. Below is an example from a facility where they use a CDS for educating the patient on Digoxin. When viewing the pop ups from the icon, they are view only at this point but become fields to document on when scanning/istering the medication in the system.
The next icon over is the two pencils
, this is the icon for co-signer required on a specific
medication. When the co-signer actually signs as a co-signer, it will occur when you file the medications and a box will pop up that has the entry for the co-signers mnemonic and after hitting enter, will bring up the box to complete the electronic signature of the cosigner. (This will be illustrated later).
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The next icon is the Criteria, Label Comment and Special Instructions icon
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shows information from the pharmacy or the provider as to parameters he/she wants the medication given under.
When the clicks on the icon it will bring up specific information entered by the provider. This will not pop up when you ister the medication but is always available as information to the . You can see this same information when you review the history of the medication in the ‘Submit’ area.
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Medication Schedule Columns: Immediately to the right of the medication area is the column for the schedule of each medication. It has a green field to distinguish it from the other columns with the schedules next to it and does not move. PRNs, Stat, and One time do not have a schedule so for those medications nothing is showing (See Below). The ED typically only uses PRN and STAT so you will not see information in the Scheduled Time column.
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Below you will see the red background on the 1154 dose of Benadryl. This indicates the medication is overdue. The green background on the Tylenol indicates the medication is w/in the timeframe to be given. After the medication has been istered this will change to a gray reverse highlight.
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The Action Buttons at the Bottom of the eMAR Desktop: Once you are to the point of performing an action against the medication profile, you have the buttons at the bottom of the eMAR Desktop that have distinct functions and uses. The document button is used to document any checked medications. You can click on the istration time located next to the Sched Time column, or as noted above you can check all meds and then click on the document button to complete the documentation process. In the below example you can click in the check box next to the med and then the “Document” button to document on that single med:
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As seen here, the istration Queries popped up for Documentation, fill out the appropriate and enter through the screen.
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Once you finish the istration Queries screen, the remaining screen gives you the ability to select “Non-Scheduled”, “Scheduled” (with a drop down box to select the correct time and date), “Given”, “Not Given”, the “istration” time and date which can be changed to reflect a different time given today, the “Dose”, “Units”, “” mnemonic, and a “Text” drop down where you can click on and enter a note with the of just this medication.
Buttons at the bottom allow you to “Document” what you have changed on this pop up box or “Cancel” documenting here.
The next button “Ack” that resides next to the Document button takes you into the Acknowledgement area.
The next button is the “Preferences” button. This gives you the ability to make changes to your eMAR view.
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eMAR reports is just what is states, they can be placed on the button or auto printed (these are Meditech standard when seen here).
The “Change Order” button allows you to “Change Order”, “D/C Order”, or “Edit Orders” depending on your access level
Lastly, the “Submit” button. Use this button after you have documented your meds and are ready to finalize the process.
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Here we are at the point of decisions and choices. On the left we can unselect any medication that we decide we don’t want to document on. The other point is looking at all the information, making sure you are filing the right time and dates, using the edit button to make changes on anything you have documented on up to this point. After saving you will need to put your in.
Once you have determined you are ready to file the medication you have the following options: 1. “Return to eMAR” button does just that; it returns me to the eMAR to do additional documentation. If I don’t return but exit the eMAR I lose everything as if I never entered the eMAR. 2. “Save and Exit” will file the medications I have and return me to the Tracker. 3. “Save and Recompile” will file the medications and return me to the eMAR.
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This is what the eMAR will look like after you have documented and saved the medications.
Anytime a medication has been given it will be gray numbers on a white background. The
next to the Tylenol is the reassessment indictor. By clicking on the icon you will
get a pop up like this if the reassessment isn’t due:
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You can chose to document anyway, or what until the reassessment time (usually 30 minutes) arrives. This particular reassessment documentation screen looks like this:
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The Medication History: Every aspect of the process of documenting in the Desktop eMAR is saved and available to view by any . Everything from when the order was placed, to documentation with a co-signer. One area to see more detail is by clicking in the ‘Ack’ area as seen below:
After clicking in the “ACK” area or by clicking “ACK” button next to Document at the bottom left of the screen you will be presented with this Review Order screen:
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You will note there is a difference of the areas seen of dark blue to light blue, dark blue is the area being viewed. By selecting a different area header above, say ‘istrations’ we see all the information just about istering the medication show up (see below).
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The “History” button shows all the activity of the order from acknowledged, interaction checking, and documentation of the medication. There is one view, which will show it all in one place and that is the “Print Order” button.
When you click on this button a box will show to where you wish to print this, if you type in ‘VIEW’ or “PREVIEW in capital letters it will load all the information contained into this area and you just scroll down to what documentation you wish to see. Here we see the actual istration of the medication that includes the CDS for the B/P. If you were to look at PCI that B/P would be there as well.
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Section 17: Changing Chief Complaint Now let’s change the chief complaint. This will also change the assessments on the Triage/Documentation screen to allow for further charting on a new chief complaint (any assessments documented and filed will not be deleted). Click on the Chief Complaint on the Private Tracker or select the edit button next to the chief complaint on the Triage/Documentation screen.
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Hit F9 for lookup or go to private tracker screen and click on the chief complaint of the patient you are charting on. This will bring up the new complaint box and you can do F9 lookup.
When you find the new complain select it. An update chief complaint screen will appear, click yes.
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Section 18: Changing Status Events Status Events are how we track patient flow.
To manually change a Status Event, use the mouse to click on the current Status Event which is below the chief complaint on the Private Tracker. This will bring up the Update Status Event Screen.
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Now type in the mnemonic of the status event you want, for example, IR = “in radiology”. You can also use F9 to bring up a list of status events and select from that menu.
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Select the correct Status Event and file.
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Section 19: Departure and Discharge Documentation To complete the DC Disposition screen highlight your patient and click Trg/Doc then click on DC Disposition. Enter “D” or on your keyboard, or click on the Documentation button.
Type “N” for now appropriate time.
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Your cursor will be blinking in a white box labeled “Pain/Comfort Reassessed?” hit Y or N, tab to Intensity and type 1 – 10, tab to D/C Vitals? type Y or N. If yes then fill in each vital sign box. Discharge Meds: is free text. Tab over to Pre-Pak # and fill in blank if patient was sent home with a Pre-Pak. If a prescription was call into a pharmacy tab to Rx called to box and type in appropriate free text. Click or tab to Discharge Status/ and hit F9 to look up or type in mnemonic. Tab to Discharged To/, Belongings-Valuables/, Aftercare Instructions/, and Discharged Via/. In each field hit F9 to look up appropriate response and click. If the patient is itted to hospital click in the Report To: field and type the name and title of the person you gave report to and tab over to time and fill in. The white boxes Equipment Used During Transfer? and Staff Present During
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Transfer/ you can use F9 and choose best response. Sedating Meds? Type Y or N and Transportation Provided By/ is an F9 look up. The Bottom white comment box is free text. When finished hit F12 to file. Next you want to depart the patient. From the tracker highlight the patient you want to depart, click Depart and press “D” or click on the Document button.
Review and confirm what the physician has entered into the screen and file.
When you are sure the information is correct hit the ok and this will take you back to the Depart screen. Click on the Depart button.
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The patient is now discharge from the emergency department. Once the charting is complete you will print one encounter for Medical Records/Billing. To print the encounter click on the Summary button or double click the patient’s name,
the encounter will come up on the screen. Click the printer icon button and make sure the “print all” box is checked and print. This should then remove the patient from the Private Tracker to the Discharged Tracker.
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Section 20: ission Documentation When the patient is ready to be itted, you will want to fill out the DC Disposition screen just like you did on a patient being discharged from the emergency department with one exception. Fill out the box “report given to” and time report was given and hit F12 to file.
Make sure when you go to Depart the patient you confirm the physician has entered the patient is itted to the hospital as inpatient or observation.
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Section 21: Documenting on the Wrong Record If you accidentally chart on the wrong patient you can easily make corrections. Select the patient from the Private Tracker and click on Trg/Doc. Double click on the Assessment or Treatment that was charted wrong or click on the (+) to the left of the Assessment/Treatment title. This will expand the assessment or treatment menu.
Highlight the assessment or treatment you want to undo and click “undo” on the far right of the screen. You can also type “U”. Click on “yes” to file.
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Note, the assessment or treatment that has been undone will not be deleted from the record; it will turn gray to indicate this documentation has been modified.
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Section 22: Editing Records After you have filed an assessment or treatment on occasion you may need to add or change information that had been entered. You can only do this if you were the individual who charted on the patient in the first place. First, highlight the patient from the Private Tracker. Click on Trg/Doc, double click the Assessment or Treatment that was charted on. You may also click on the (+) to the left of the Assessment or Treatment and expand the menu. Highlight the Assessment or Treatment you want to edit and click “Edit/Amend” or hit “E” on your keyboard.
You may now make your changes and then hit F12 to file.
EDM
You can now see the record has been edited.
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Section 23: Patients Accidentally Departed If you accidentally depart a patient from the tracker, or make the Status Event “Discharged” before all documentation is complete it can be undone. First you must back out to the EDM Main Menu.
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Click on Patient Routines and a pop up menu will appear, from the list click on “Update Status Event”.
EDM First type in the patient name and search for the correct patient.
You can see patient Tonka Truck is IN RAD.
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To change the status event click in the New Status Event box and hit F9. A menu of status events will appear, choose your new Status Event and click “OK”.
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Section 24: Clinical Review The “Review” button launches clinical review known as EPS or Extra PCI Database Source. “Review” allows you to review the latest patient data, for example, results, the patient summary, order history, PCI, and other visits. Nursing assessments can also be seen here. To launch Clinical Review simply click the “Review” button on the Integrated Desktop. If you would like to launch Clinical Review on a patient who is not on the tracker simply use the Magic Key menu by hitting shift and F12.
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When Clinical Review is launched you will see the patients’ demographics at the top of the screen. On the right of the screen highlighted in red is the Verb Strip, these buttons allow you to navigate through Clinical Review.
FYI: At the bottom left of the screen you have the option to ask for help email
, or use the web
,
. You may also launch PCI or Order entry by clicking the buttons
on the bottom of the screen. If at anytime you want to return to the Private Tracker click Patient List on the bottom of the Verb Strip.
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“Pt Summary” shows general information on your patient. /Demographics are also available here. When clicked you will see the following screen:
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“Special ” gives access to s that Meditech has built to cover provider specialties. If labs have been resulted that are included in these s they will be available to view. After viewing a use the “Back” button to return to this screen. When the ALL LAB Results button is clicked in this screen an easy to read lab report is generated.
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“Order History” shows details on all the orders that have been placed on your patient. When clicked you will see the above screen:
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“Lab” shows recent lab results. When clicked you will see “lifetime Summary” this will show lab results from November 2008 to present. Data prior to this date is in PCI.
EDM Microbiology tab will launch microbiology results if the patient had this type of test done.
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Blood Bank and Pathology will generate reports if the patient had this type of testing done. If there are no results to be seen the button will be gray.
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The Medications button will generate a report which will allow you to see medications ordered for the patient, the dose, route, start and stop date, status, and when last istered.
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The Imaging tab will launch imaging reports, Other Reports tab will allow you to view many different kinds of reports, for example, dictations, and Notes History will allow you to see physician notes which have been filed.
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“Assessments” will show nursing documentation.
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“Other Menu” is a way of building a with I & O and meds or you can launch the Reconciled Medication screen.
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“Other Visits” allows access to data from other visits to the hospital this patient has had. Information will be available for the other buttons in this screen as tests are completed for those categories.
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Section 25: Patient Care Inquiry
Section 19: Patient Care Inquiry (PCI) Patient Care Inquiry (PCI), allows you to move into historical data on the selected patient. PCI provides access to history, lab, radiology, and other data that has been documented on this patient within our regional hospitals. PCI allows you to access the following information in a Patient’s Chart: Orders istrative Data Current and historical medications Hospital visits (w/abstracts) issions Information Laboratory, Microbiology, Anatomical Pathology, and Blood Bank Radiology Exams and Reports Recent Clinical Results Ancillary Dept. orders and results Three important tools help you navigate through PCI with minimal keystrokes: 1. Highlighter Bar 2. Arrow Keys 3. Control Key
Highlighter Bar- horizontal bar that highlights an entry on the screen . You move it up and down the list of entries using the arrow key. Arrow Keys- perform the following functions: *Move the highlighter bar up and down the list of entries. *Allow you to view the highlighted entry in more detail. *Allow you to return to the previous screen. Control Key-allows you to select multiple screen entries on which you want to execute a verb strip command. 1. Move the highlighter to the entry. 2. Press
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NOTE: For on-line documentation, simply hold down <Shift> and
That will bring up the PCI screen.
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The PCI Identify Patient Menu After you select PCI from your Main Menu, the system displays the Identify Patient window, which lists several methods of identifying patients. Use the up and down arrows to move the highlight bar to what you want to select then right arrow to view your selection. The PCI Menu lists several methods of identifying a patient in the Identify Patient Window.
IDENTIFYING A PATIENT BY NAME, NUMBER
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IDENTIFYING A PATIENT BY SOUNDEX NAME:
This method of identifying patients enables you to identify all patients with a medical record whose name matches the criteria entered. This feature helps you locate a patient’s record in the event you are unsure of spelling.
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Viewing Data in PCI Once you have navigated to the correct patient you will be taken to the PCI Table of Contents screen. This screen provides you with different options use the up and down arrows and place the highlight bar on an entry to select. Right arrow to view selected entry. The Verb Strip shows the functions that may be performed on this screen.
PCI uses windows to display patient information in a logical, step-by- step manner, moving from general to detailed. The Table of Contents displays all information available for a patient. Once you identify which category you would like to know more about, the ensuing windows provide increasing levels of detail.
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To view data highlight what you want from the table of contents and right arrow to next screen.
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You will be taken to the summary window, choose what you want to view and right arrow over to next screen.
EDM You have now launched to the history screen, right arrow over to next screen.
You are now at the detail window and can view results.
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Split Screen Feature The split screen feature enables you to simultaneously view data from two different sources at any Summary or History Window. Clinical staff may find this useful when comparing two different laboratory results.
Click to print
Click full to return to full screen
After you have the summary or history window of one clinical result on your screen, enter an “S”. The Table of Contents window appears. Select the date source and nd
highlight the 2 item you wish to view. Press the right arrow key twice or after you right arrow in the table of contents screen enter “S” or click Split. To return to full screen type “F” or click Full.
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Printing and Other Verb Strip Functions Most of the reports in PCI are printed from the History window by selecting the verb command “P”. A pop up Box with “Print this history report” and “Print details of the highlighted item” will appear. Make your appropriate selection,
EDM Then choose which printer.
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The Bulletin Board is used as a communications tool between clinicians. Information entered into the Bulletin Board may be viewed by all clinical staff that accesses the patient.
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Clinical Highlights is a defined data source on the Table of Contents where you can group frequently viewed data on one screen for patients you specify. Entire data sources can be added or specific entries from the summary window can be added. This feature is and patient specific.
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Click to go over to next screen Patient Summary will allow you to quickly access the patient’s summary.
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Click to view reconciled medications
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Choose which query you would like to view and right arrow over to open Medication Recon screen.
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Viewing Discharge Instructions Scroll the highlight bar down to “Emergency Department Data” and right arrow key over to next screen.
EDM Highlight “Pt Instructions” and right arrow over to view.
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Appendix A (Chief Complaints)
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Appendix B (Assessments)
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Appendix C (Treatment Indicators)
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References A g g a b a o S t a c e y, S . A . ( 2 0 1 1 ) . E m e r g e n c y d e p a r t m e n t m a n a g e m e n t [Electronic mailing list message]. Retrieved from https://webmail.pullmanregional.org/owa/ In l an d No rt h wes t Heal t h S erv i ce (INHS ), In i t i als . (20 11 ). M edi t ech nursing training manual emergency department (edm). h t t p : / / w w w. i n h s . i n f o /
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