Download ChartLink 5 - Anaheim Regional Medical Center

ChartLink 5 ChartLink 5 ChartLink 5 by Computer Programs & Systems, Inc. Computer Programs & Systems, Inc. 6600 Wall Street Mobile, Alabama 36695 Phone: 251.639.8100 Fax: 251.639.8214 Internet Address: www.cpsinet.com ChartLink 5 Copyright © 2013 by Computer Programs and Systems, Inc. All rights reserved. This publication is provided for the express benefit of, and use by, CPSI Client Facilities. This publication may be reproduced by CPSI clients in limited numbers as needed for internal use only. Any use or distribution outside of this limitation is prohibited without prior written permission from CPSI. The reception of this publication by any means (electronic, mechanical, photocopy, downloading, recording, or otherwise) constitutes acceptance of these terms. Trademarks: The CPSI logo, as it appears in this document is a Trademark of Computer Programs and Systems, Inc. Limitations: CPSI does not make any warranty with respect to the accuracy of the information in this document. CPSI reserves the right to make changes to the product described in this document at any time and without notice. Version : 18 Published : 2013 Computer Programs & Systems, Inc. 6600 Wall Street Mobile, Alabama 36695 Phone: 251.639.8100 Fax: 251.639.8214 Internet Address: www.cpsinet.com Table of Contents I Table of Contents Chapter 1 Introduction Overview ............................................................................................................... 1 ............................................................................................................... 1 What's New Chapter 2 Chartlink 5 access Overview ............................................................................................................... 3 ............................................................................................................... 3 Signing On/Off Chartlink Chapter 3 Home Screen Overview ............................................................................................................... 5 Chapter 4 Charts Overview ............................................................................................................... 7 ............................................................................................................... 7 Whiteboard Features ............................................................................................................... 9 Name Search ............................................................................................................... 10 Number Search ............................................................................................................... 10 Nursing Search ............................................................................................................... 12 Search by Doctor RegNew ............................................................................................................... 12 Chapter 5 E-Sign Overview............................................................................................................... 13 ............................................................................................................... 13 Other - Electronic Signature Processes Signing for Other Physicians ......................................................................................................... Cosignatures for Mid-level Practicioners ......................................................................................................... Cosignature DC Reasons ......................................................................................................... Verbal Order DC Reasons ......................................................................................................... Image 17 17 19 20 ............................................................................................................... 21 Key ............................................................................................................... 21 Chapter 6 Reports Overview............................................................................................................... 23 Chapter 7 Summary Screen Overview............................................................................................................... 25 Access ............................................................................................................... 25 Meds ............................................................................................................... 26 Labs ............................................................................................................... 28 II ChartLink 5 Vitals ............................................................................................................... 31 Chapter 8 Physician Problem List Overview............................................................................................................... 33 Chapter 9 Allergies Overview............................................................................................................... 35 Access ............................................................................................................... 35 ............................................................................................................... 35 Allergy Maintenance Chapter 10 Medication Reconciliation Overview............................................................................................................... 37 Chapter 11 Prescription Entry Overview............................................................................................................... 39 Chapter 12 Immunizations Overview............................................................................................................... 41 Access ............................................................................................................... 41 ............................................................................................................... 41 Immunization Maintenance Chapter 13 PACS Overview............................................................................................................... 45 Chapter 14 Order Chronology Overview............................................................................................................... 47 Access ............................................................................................................... 47 ............................................................................................................... 47 Order Chronology Screen Chapter 15 Transcriptions Overview............................................................................................................... 49 Access ............................................................................................................... 49 ............................................................................................................... 49 Transcriptions Screen Chapter 16 Clinical History Overview............................................................................................................... 51 Access ............................................................................................................... 51 ............................................................................................................... 51 Clinical History Screen Chapter 17 Attachments Overview............................................................................................................... 53 ............................................................................................................... 53 Vital Signs Graphic I......................................................................................................... &O Swan Ganz ......................................................................................................... 53 58 Table of Contents III O2 Sat Bar Graph ......................................................................................................... Critical Care Flow Sheet ......................................................................................................... All Critical Care Flowsheets ......................................................................................................... Growth Charts ......................................................................................................... Attachments ......................................................................................................... 61 63 67 71 74 ............................................................................................................... 75 Medical Records Overview......................................................................................................... Attachments ......................................................................................................... 76 77 Orders ............................................................................................................... 79 Physician's Nursing Order Report ......................................................................................................... 80 Attachments ......................................................................................................... 82 ............................................................................................................... 84 Laboratory Comparative All - This Stay ......................................................................................................... Comparative/Department - This Stay ......................................................................................................... Comparative - All Stays ......................................................................................................... Comparative/Departments - All Stays ......................................................................................................... Comparative - Multifacility ......................................................................................................... Detail Report ......................................................................................................... Attachments ......................................................................................................... 85 88 90 92 94 95 98 ............................................................................................................... 99 Medication MAR Final ......................................................................................................... ......................................................................................................................................... Demographics Box ......................................................................................................................................... One Time Orders ......................................................................................................................................... Scheduled/Routine Medications ......................................................................................................................................... IV Orders 100 MAR Temporary ......................................................................................................... ......................................................................................................................................... Demographics Box ......................................................................................................................................... One Time Orders ......................................................................................................................................... Scheduled/Routine Medications ......................................................................................................................................... IV Orders ......................................................................................................................................... PRN Medications 106 All MARs ......................................................................................................... All 5 Day MARs ......................................................................................................... Scheduled Medications ......................................................................................................... PCA ......................................................................................................... ......................................................................................................................................... PCA Infusion Form Medication Record ......................................................................................................... Medication Reconciliation Report ......................................................................................................... Attachments ......................................................................................................... 113 115 118 121 103 103 104 106 109 109 110 112 112 121 122 125 127 ............................................................................................................... 129 Radiology Overview ......................................................................................................... 130 ............................................................................................................... 130 Multi Disciplinary Discharge Planner ......................................................................................................... Problem List ......................................................................................................... Problem Activities ......................................................................................................... Care Plan ......................................................................................................... Discharge Summary ......................................................................................................... Discharge Instructions ......................................................................................................... Transfer Form ......................................................................................................... Initial Interview ......................................................................................................... Initial Physical Assessment ......................................................................................................... Patient......................................................................................................... Progress Notes Attachments ......................................................................................................... 131 133 137 140 142 144 147 150 152 155 157 IV ChartLink 5 158 Nurses ............................................................................................................... Notes Initial Interview ......................................................................................................... Initial Physical Assessment ......................................................................................................... Patient......................................................................................................... Progress Notes 24 Hour......................................................................................................... Summary Shift Summary ......................................................................................................... Attachments ......................................................................................................... 159 162 166 172 179 181 ............................................................................................................... 183 Education Education Report ......................................................................................................... Attachments ......................................................................................................... 183 186 ............................................................................................................... 188 Cardiopulmonary Initial Interview ......................................................................................................... Initial Physical Assessment ......................................................................................................... O2 Saturation Graph ......................................................................................................... Comparative ......................................................................................................... Comparative-All Stays ......................................................................................................... Comparative-Multifacility ......................................................................................................... Detail Results ......................................................................................................... Attachments ......................................................................................................... 188 192 194 196 199 200 202 205 ............................................................................................................... 206 Rehabilitation Initial Interview ......................................................................................................... Initial Physical Assessment ......................................................................................................... Attachments ......................................................................................................... 207 212 213 Dietary ............................................................................................................... 215 Initial Interview ......................................................................................................... Initial Physical Assessment ......................................................................................................... Nutritional Calculations ......................................................................................................... Attachments ......................................................................................................... 215 218 219 221 ............................................................................................................... 222 Diabetic Cumulative Report ......................................................................................................... Daily Diabetic Report ......................................................................................................... Weekly......................................................................................................... Report Attachments ......................................................................................................... 223 225 228 231 ............................................................................................................... 232 Miscellaneous Census......................................................................................................... Report Attachments ......................................................................................................... 233 236 ............................................................................................................... 237 Face Sheet Face Sheet ......................................................................................................... Attachments ......................................................................................................... 238 241 Other ............................................................................................................... 243 Attachments ......................................................................................................... 243 Chapter 18 CPOE ............................................................................................................... 247 Overview Chapter 19 Physician Documentation ............................................................................................................... 249 Overview Chapter 20 HIR ............................................................................................................... 251 Overview Table of Contents V Chapter 21 Temporary Registration ............................................................................................................... 253 RegNew ............................................................................................................... 253 Whiteboard Function 254 Patient ............................................................................................................... Function Screen Chapter 22 ChartLink Reference ............................................................................................................... 257 Overview ............................................................................................................... 257 ChartLink Tables ChartLink Groups ......................................................................................................... ChartLink Control Table Page 1 ......................................................................................................... ChartLink Control Table Page 2 ......................................................................................................... 258 260 261 Introduction Chapter 1 1.1 1 Introduction Overview ChartLink 5 is designed to provide the physician and clinical staff a portal to the Electronic Medical Record with patient information organized and easily presented. ChartLink 5 provides the clinician real-time access to all of a patients current encounter data and complete clinical history to facilitate communication and coordination to enhance patient safety and quality of care, manage patient treatment, eliminate lost charges and improve reimbursement. Features and benefits of ChartLink 5 are: · Patient information is available interactively and in real time · Communication and security is compliant with current HCFA Internet Policy and proposed HIPAA rules · Intuitive screen designs with the use of icons and toolbars · Multiple patient charts may be opened at the same time · Ability to toggle between accounts without closing documents · Users may toggle between reports on an account · Users may toggle between separate applications 1.2 What's New This section introduces the new features and improvements for ChartLink 5 for release Version 18 and 1850. A brief summary of each enhancement is given in referencing its particular location if applicable. Each enhancement includes the Work Request (WR) Number, the description and the implemented release Version. If further information is needed, please contact CPSI. There are no new enhancements for this application in Version 18 and 1850. © 2013 Computer Programs and Systems, Inc. 2 ChartLink 5 © 2013 Computer Programs and Systems, Inc. Chartlink 5 access Chapter 2 2.1 3 Chartlink 5 access Overview This section will explain how to sign on and off the ChartLink 5 application. NOTE: CPSI Clinical Software is being converted to new maps. Some of these new maps may be seen throughout this user guide. When new maps are released for an application, CPSI will add those maps to the next set of user guides that are published. 2.2 Signing On/Off Chartlink The ChartLink 5 system requires the physician to sign onto the system before he or she can access the application. The hospital’s Information Technology department issues physician numbers, passwords and maintains security settings. To track physician login and other physician functions within the software, consult the A/R audit trail system that exists within the Special Functions module. · Users logging in via a Physician Web Icon or via a CW5 desktop Icon will utilize the CPSI runner for access. § Facility and Application access settings are configured by the Hospitals Information Technology department. NOTE: ChartLink 5 may also be accessed by staff other than physicians. Access to ChartLink 5 is controlled by employee security. Refer to facility Information Technology Department for further information. © 2013 Computer Programs and Systems, Inc. 4 ChartLink 5 Select ChartLink Signon Screen Runner Figure 2.1 Runner NOTE: If a Patient Account is selected in the traditional ChartLink application and access is gained to either the Physician Problem List or Physician Documentation applications, the ChartLink 5 application will open. The user may then select on the Summary Screen icon located at the top of the ChartLink 5 Icon Bar. The user may also access the ChartLink 5 application when accessing the Medication Reconciliation application through CPOE. © 2013 Computer Programs and Systems, Inc. Home Screen Chapter 3 3.1 5 Home Screen Overview This ChartLink 5 feature is currently under development. Select ChartLink 5 sign on > Home Screen Figure 3.1 Home Screen © 2013 Computer Programs and Systems, Inc. 6 ChartLink 5 © 2013 Computer Programs and Systems, Inc. Charts Chapter 4 4.1 7 Charts Overview This section of the ChartLink 5 User Guide will explain the features located under the Charts Icon. Select ChartLink 5 sign on > Charts Figure 4.1 Charts Icon NOTE: Patient account access may be limited per hospital policy and procedures. Emergency access to any patient account by any provider may be accomplished utilizing an emergency access. The user will be prompted that they are not authorized to view this patient. Access is monitored. 4.2 Whiteboard Features Upon access to the Whiteboard · Defaults to My Patients Inpatient List § Patient accounts listed as the Physician of Record o Attending o Primary o Consultant § Patients listed are registered as Stay Type 1 § Patients list in Alphabetical order by Last Name © 2013 Computer Programs and Systems, Inc. 8 ChartLink 5 Select ChartLink 5 Whiteboard Figure 4.2 Whiteboard · My Practice Patients Selection § List all Patient accounts within the same ChartLink Group Code 258 assigned to User. · A Subcategory filter is available as a drop-down menu to determine other My Patient types to view § Outpatients list all Stay Type 2,3,4 and 5 for User § The Discharged list will display all patients accounts that have been discharged within the last 14 days regardless of Stay Type § The Watchlist will display any Patient account that has been selected to add utilizing the Plus Man Icon from Whiteboard List · A Subcategory filter is available as a dropdown menu to determine other My Practice Patient types to view § Outpatients list all Stay Type 2,3,4 and 5 for User § The Discharged list will display all patients accounts that have been discharged within the last 14 days regardless of Stay Type · Select Blue Arrow bottom left of screen to return to previous screen. © 2013 Computer Programs and Systems, Inc. Charts 9 NOTE: Patient account access may be limited per hospital policy and procedures. Emergency access to any patient account by any provider may be accomplished utilizing an emergency access. The user will be prompted that they are not authorized to view this patient. Access is monitored. 4.3 Name Search Search by Name Icon Profile Listings. may be selected to display a Master Patient search from · Begin desired Patient search by typing in the Patient' s Last Name § This is a Smart Search feature, start typing in letters of the Patients last name until desired Patient displays. · Three options are given to selecting the desired Patient Account. · List Patient Visits § Display of Each Visit sorted by Admit Date. § Fields include age, visit type, room number, and diagnosis of that visit. § Selection of the desired Name will direct the user to that Patients Chart. · Most Recent Hospital Visit § Opens Patients chart for most recent or current hospital stay. · Most Recent Clinic Visit § Opens Patients chart for most recent or current clinic visit. § Facility must be using CPSI MP-EMR application. © 2013 Computer Programs and Systems, Inc. 10 ChartLink 5 Select ChartLink 5 Whiteboard > Name Figure 4.3 Name Search · Select Blue Arrow bottom left of screen to return to previous screen. NOTE: Patient account access may be limited per hospital policy and procedures. Emergency access to any patient account by any provider may be accomplished utilizing an emergency access. The user will be prompted that they are not authorized to view this patient. Access is monitored. 4.4 Number Search Search by Number Icon may be selected to display a Specific Visit. · A known Account number entered will open the desired Patients Chart. · Patient not Found will display for erroneous numbers · Select Blue Arrow bottom left of screen to return to previous screen. NOTE: Patient account access may be limited per hospital policy and procedures. Emergency access to any patient account by any provider may be accomplished utilizing an emergency access. The user will be prompted that they are not authorized to view this patient. Access is monitored. 4.5 Nursing Search The Nursing Icon will display a list of the Nursing Stations. · Selection on the desired Nursing Station will display a list of the Patients present on that © 2013 Computer Programs and Systems, Inc. Charts 11 Nursing Station. · Selection on the desired Patient Account will display chart. · Select on the Green Plus Sign with the man icon far right to add the Patient to Watch List. · Select Blue Arrow bottom left of screen to return to previous screen. Select ChartLink 5 Whiteboard > Nursing Figure 4.4 Nursing Station Search NOTE: Patient account access may be limited per hospital policy and procedures. Emergency access to any patient account by any provider may be accomplished utilizing an emergency access. The user will be prompted that they are not authorized to view this patient. Access is monitored. © 2013 Computer Programs and Systems, Inc. 12 4.6 ChartLink 5 Search by Doctor Select the Doctor icon to access search options. · A list of Facility Physicians will display § Narrow search options by typing desired Physician name. · Selection of desired Physician will display the Inpatient Whiteboard for that specific Physician Select ChartLink 5 Whiteboard > Doctor Figure 4.5 Doctor Search NOTE: Patient account access may be limited per hospital policy and procedures. Emergency access to any patient account by any provider may be accomplished utilizing an emergency access. The user will be prompted that they are not authorized to view this patient. Access is monitored. 4.7 RegNew · The Register feature should only be used with CPOE. · Policy and procedures will need to be established to determine how and when Providers should use this option. Refer to the Temporary Registrations section in the Registration User Guide for further information on creating a temporary registration. © 2013 Computer Programs and Systems, Inc. E-Sign Chapter 5 5.1 13 E-Sign Overview This section of the ChartLink 5 User Guide will discuss the E-Sign feature located on the ChartLink 5 User Icon Bar. Select ChartLink 5 sign on > E-Sign Figure 5.1 E-Sign 5.2 Other - Electronic Signature Processes Electronic Signature is a feature that provides dictating physicians the ability to electronically view, edit and sign their transcribed documents. The electronic signature includes the physician’s name and credentials but is not an actual handwritten or scanned signature. This feature includes: · Viewing and editing transcribed documents online before signing. · Signing transcribed documents for another physician in the same group. · Allowing for a "second" co-signature for those documents or orders requiring such authentication when initiated by a mid-level provider (such as a Nurse Practitioner or Physician Assistant). · Accessing the E-Sign application: 1. Enter physician number and password to access the ChartLink 5 application. NOTE: The physician number will display when it is typed in, but the password will NOT display. 2. Select Electronic Signature, located in the bottom portion of the screen. If a site is using the Whiteboard feature, the esign icon is located at the top of the patient selection screen. 3. Select Edit, Sign, or View by clicking in the radio button next to the document. To select ALL orders, select the word Edit, Sign, or View above the radio buttons. 4. The transcribed documents that appear on this screen may be sorted by selecting the headers © 2013 Computer Programs and Systems, Inc. 14 ChartLink 5 at the top of the screen (Patient, Account Number, Document Desc. and Status/Date). 5. Once the documents have been selected, select PROCESS. NOTE: If documents are selected to sign and have not been viewed or edited, a warning will display. © 2013 Computer Programs and Systems, Inc. E-Sign 15 Select ChartLink 5 Sign On > E-Sign > Electronic Signature Figure 5.2 Esign 6. The document will display in Microsoft® Word for viewing or editing. Figure 5.3 Wordä Transcription © 2013 Computer Programs and Systems, Inc. 16 ChartLink 5 7. After the report has been edited in Microsoft® Word, select Save/Sign. · Enter passphrase and select Sign. · To return the transcription for editing select Edit/Return. © 2013 Computer Programs and Systems, Inc. E-Sign 17 Signing for Other Physicians · A physician may sign documents for another physician or mid-level practicioner if he/she has been given permission to do so. The covering physician’s number must be setup in Physician Security on the physicians table he is signing for. · Once E-sign is accessed, the covering physician must choose the physician he is signing for from the dropdown box to have the documents display in the E-sign que. · Once the documents are displayed, the physician may E-sign using the normal signing process. Cosignatures for Mid-level Practicioners Co-signature of Transcriptions for Mid-level Providers: A transcription mnemonic, <<CO-SIGNATURE_PENDING>> , may be inserted into any transcription template (order entry or medical records) to allow for co-signature. This mnemonic may be placed in either the header/footer section or the body of the template. This mnemonic will fulfill when the co-signing physician signs the document (the "2nd" signature) and will pull in a combination of the information in the "Co-signed by label" field plus the information brought forth via the DCTNAME mnemonic (the signing physician's name as input in Physician Security. This mnemonic will "blank" itself out if the transcription was dictated by the physician and hence does not require a co-signature. Therefore, this mnemonic may be placed in all transcription templates and does not require setting up additional templates simply to accomodate a co-signature scenario, nor will the mnemonic remain unfulfilled in the report if the physician is the first and only one who would sign the document. Also, some of the fields in the physician security tables are used to allow for the co-signature process and to allow a mid-level provider to have orders and transcriptions co-signed. Require Additional Sig? Co-signer? If Y is entered, the provider is required to have any orders, transcriptions and verbal and telephone orders initiated by him/her to be co-signed by a "Co-signer:" (either an individual six digit physician number or a ChartLink group code entered in the field directly adjacent). If P (prompt) is entered, a list of providers to co-sign the transcription will be presented during the Electronic Signature process, but do not require selection of a provider's name from the list. NOTE: Any co-signing physician will see a list of documents from any mid-level providers for whom they are responsible for co-signing. This will list in the signing physician's queue broken out below their normal electronic signature documents when the co-signing physician logs into electronic signature. Send trans. when mid-level signs? This field determines when a transcription is auto-distributed after Electronic Signature. This field need only be set for physicians or providers (NOT requiring a co-signature) with mid- levels working under their supervision. This field works in conjunction with the existing report distribution fields and settings for both order entry and medical records transcriptions. The options are as follows: · S - The transcription will be auto-distributed when the mid-level signs the document (1st signature) · C - The transcription will be auto-distributed after the supervising physician co-signs the © 2013 Computer Programs and Systems, Inc. 18 ChartLink 5 document (2nd signature) · B - The transcription will be auto-distributed after the mid-level signs and again after the supervising physician signs. In this scenario the report will be sent twice. Co-signed by label: The information in this field will pull to any transcription that uses the <<CO-SIGNATURE_PENDING>> mnemonic. The wording in this field is used in combination with a co-signing supervising physician. Example: Co-signed by label has the following phrase loaded in the field: "Electronically Reviewed and Co-signed by:" When the co-signing physician (ex John Doe M.D) signs the document that was previously signed by the mid-level provider, the co-signing physician's name will pull to the transcription and it will read: Electronically Reviewed and Co-signed by John Doe M.D. NOTE: Any Provider set to require a co-signature will have the ability to select a different co-sign physician each time a document is signed within the same session. The co-signing physicians credentials will pull from page 1 of the physician security © 2013 Computer Programs and Systems, Inc. E-Sign 19 Cosignature DC Reasons Select Hospital Base Menu > Master Selection > Business Office Tables > Maintenance > CL Tables > Cosignature DC Reasons Figure 5.4 ChartLink Physician Cosignature DC Reasons ChartLink 5 Cosignature DC Reasons can be created to give physicians the ability to choose from a list of acceptable reasons to discontinue orders that required the physician's signature as a cosignature. Please see the CPSI Electronic Signature User Guide for more information regarding the functionality of cosignatures. © 2013 Computer Programs and Systems, Inc. 20 ChartLink 5 Verbal Order DC Reasons Select Hospital Base Menu > Master Selection > Business Office Tables > Maintenance > CL Tables > Verbal Order DC Reasons Figure 5.5 ChartLink Physician Verbal Order DC Reasons ChartLink® Verbal Order DC Reasons can be created to give physicians the ability to choose from a list of acceptable reasons to discontinue verbal orders that have been placed within the CPSI system. © 2013 Computer Programs and Systems, Inc. E-Sign 5.3 21 Image The Image area displays a list of unsigned documents that have been scanned into the Patients account record and are present for Provider review and signing Select ChartLink 5 sign on > E-Sign > Image Figure 5.6 Esign Image 5.4 Key This area will allow the Provider an area to change their passphrase. The Passphrase must be defined before any documents can be electronically signed. The passphrase applies the physician ’s signature to the transcribed document. It can be changed anytime the physician feels security has been compromised. The passphrase must have a minimum of 10 characters, and include 1 upper case alphabetic character, 1 lower case alphabetic character, 1 numeric character and no special characters. 1. From the CPSI Electronic Signature screen, select Key. 2. Enter the passphrase twice for confirmation and then select Accecpt © 2013 Computer Programs and Systems, Inc. 22 ChartLink 5 Select ChartLink 5 sign on > E-Sign > Key Figure 5.7 Key Icon for Changing Passphrase © 2013 Computer Programs and Systems, Inc. Reports Chapter 6 6.1 23 Reports Overview This ChartLink 5 feature will be available in a future release. © 2013 Computer Programs and Systems, Inc. 24 ChartLink 5 © 2013 Computer Programs and Systems, Inc. Summary Screen Chapter 7 7.1 25 Summary Screen Overview This chapter will discuss the Summary Screen features. 7.2 Access · Upon selection of a patient account from the ChartLink 5 Whiteboard, the Summary Screen will launch. § Labs will open as default § Current medications may be viewed with selection of the Meds radio button § Current vital signs may be viewed with selection of the Vitals radio button. § A Refresh icon is present to view the latest updated changes Select ChartLink 5 Whiteboard > Select Patient Account > Summary Screen Figure 7.1 Summary Screen NOTE: If a Patient Account is selected in the traditional ChartLink application and access is gained to either the Physician Problem List or Physician Documentation applications then the ChartLink 5 application will open. The user may then select on the Summary Screen icon located at the top of the ChartLink 5 Icon Bar. The user may also access the ChartLink 5 application when accessing the Medication Reconciliation application through CPOE. © 2013 Computer Programs and Systems, Inc. 26 7.3 ChartLink 5 Meds · Select the Meds radio button located on the Summary Screen to access a list of Active and All medications that have been ordered for a patient. Select ChartLink 5 Whiteboard > Select Patient Account > Summary Screen >Meds Figure 7.2 Meds Summary · If there are no medications ordered for this patient account "No Data" will display · A Refresh Icon is present to view the latest updated changes. · A list of Active Medications for this account will display by default. · A list of All Medications for this account display upon selection of the All radio button. · The Long Description of the medication display in the vertical column. § Medication Dosage, Route and Frequency display below the Long Description. Select ChartLink 5 Whiteboard > Select Patient Account > Summary Screen >Meds Figure 7.3 Meds Vertical Column · Medication Due Dates display in the horizontal column. § Dates list in Reverse Chronological order. § Medication Scheduled Times display § Given will display upon recorded administration of the medication. § Given* will display for any recorded administration of the medication given late. § Omitted* displays for any medication not given for the scheduled time. © 2013 Computer Programs and Systems, Inc. Summary Screen 27 Select ChartLink 5 Whiteboard > Select Patient Account > Summary Screen >Meds Figure 7.4 Summary Medication Screen NOTE: If a Patient Account is selected in the traditional ChartLink application and access is gained to either the Physician Problem List or Physician Documentation applications then the ChartLink 5 application will open. The user may then select on the Summary Screen icon located at the top of the ChartLink 5 Icon Bar. The user may also access the ChartLink 5 application when accessing the Medication Reconciliation application through CPOE. © 2013 Computer Programs and Systems, Inc. 28 7.4 ChartLink 5 Labs · The Labs selection screen will open as default upon entering the Summary Screen. Select ChartLink 5 Whiteboard > Select Patient Account > Summary Screen > Labs Figure 7.5 Labs Default · A Refresh icon is present to view the latest updated changes. · If no labs have been resulted for this patient account "No Results Found" will display. · The Lab Test Name will display in the vertical column. § Normal Reference Range results will list with the Lab Test name. · Collection Date and Time will display in the horizontal column. § If the lab has been collected though not resulted then "Pending" will display in the results area next to the ordered lab. Select ChartLink 5 Whiteboard > Select Patient Account > Summary Screen > Labs Figure 7.6 Pending Lab Orders § If the lab has been collected and resulted then the results will show next to the ordered lab. Select ChartLink 5 Whiteboard > Select Patient Account > Summary Screen > Labs Figure 7.7 Resulted Labs © 2013 Computer Programs and Systems, Inc. Summary Screen 29 § If the lab result is High (H), Low (L), Critical High (HC), or Critical Low (CL) then the result will be highlighted in red. Select ChartLink 5 Whiteboard > Select Patient Account > Summary Screen > Labs . Figure 7.8 Abnormal Resulted Labs © 2013 Computer Programs and Systems, Inc. 30 ChartLink 5 Select ChartLink 5 Whiteboard > Select Patient Account > Summary Screen > Labs Figure 7.9 Summary Lab Screen © 2013 Computer Programs and Systems, Inc. Summary Screen 31 NOTE: If a Patient Account is selected in the traditional ChartLink application and access is gained to either the Physician Problem List or Physician Documentation applications then the ChartLink 5 application will open. The user may then select on the Summary Screen icon located at the top of the ChartLink 5 Icon Bar. The user may also access the ChartLink 5 application when accessing the Medication Reconciliation application through CPOE 7.5 Vitals · Select the Vitals radio button located on the Summary Screen to access recorded vital signs for selected Patient Accounts. Select ChartLink 5 Whiteboard > Select Patient Account > Summary Screen > Vitals Figure 7.10 Vitals Summary · If there are no Vital Signs recorded for the Patient Account then "No Data" will display. · A Refresh Icon is present to view the latest updated changes. · The vertical columns display vital signs that have been documented against. · The horizontal column displays date and time when the vital sign information was recorded in reverse chronological order. Select ChartLink 5 Whiteboard > Select Patient Account > Summary Screen > Vitals Figure 7.11 Summary Screen Vital Signs © 2013 Computer Programs and Systems, Inc. 32 ChartLink 5 NOTE: If a Patient Account is selected in the traditional ChartLink application and access is gained to either the Physician Problem List or Physician Documentation applications then the ChartLink 5 application will open. The user may then select on the Summary Screen icon located at the top of the ChartLink 5 Icon Bar. The user may also access the ChartLink 5 application when accessing the Medication Reconciliation application through CPOE. © 2013 Computer Programs and Systems, Inc. Physician Problem List Chapter 8 8.1 33 Physician Problem List Overview · The Physician Problem List is a purchased application. Please see your CPSI Marketing Rep for further details and implementation. · The Probs icon is an access portal to the Physicians Problem List application. Please see the separate user guide for further usage explanation. · If a Patient Account is selected in the traditional ChartLink application, and access is gained to the Physician Documentation applications, the ChartLink 5 application will open. The user may select on the Physicians Problem List icon located at the top of the ChartLink 5 Icon Bar. The user may also access the ChartLink 5 application when accessing the Medication Reconciliation application through CPOE. Select ChartLink 5 Whiteboard > Select Patient Account > Physician Problem List Figure 8.1 ChartLink 5 Icon Bar © 2013 Computer Programs and Systems, Inc. 34 ChartLink 5 © 2013 Computer Programs and Systems, Inc. Allergies Chapter 9 9.1 35 Allergies Overview This section of the ChartLink 5 user guide will discuss the ability to add and maintain Allergies to a patient's account. 9.2 Access · The Alrgy Icon is an access portal to the Allergy Maintenance Screen. · If a Patient Account is selected in the traditional ChartLink application and access is gained to either the Physician Problem List or Physician Documentation applications, the ChartLink 5 application will open. The user may then select on the Allergies icon located at the top of the ChartLink 5 Icon Bar. The user may also access the ChartLink 5 application when accessing the Medication Reconciliation application through CPOE. Select ChartLink 5 Whiteboard > Select Patient Account > Allergies Figure 9.1 ChartLink 5 Icon Bar 9.3 Allergy Maintenance · A list of active Allergies will list by default upon access. § A filter is available to display removed Allergies. · Select on a column header to arrange the list by desired choice. · Double click a listed Allergen to edit information. § The Allergen may be Saved or Deleted. · An Allergy may be added to a patients account by selecting Add New § A Micromedex generated list will be available for Allergy choice. § Type the first character of the Allergen in the search box. § The generated list will include environmental, and food allergies. § This list includes generic drugs, brand name drugs, drug classes and excipients. © 2013 Computer Programs and Systems, Inc. 36 ChartLink 5 Select ChartLink 5 Whiteboard > Select Patient Account > Allergies > Add New Figure 9.2 Allergy Search for Allergens not found in the list. § Select Add Other § Clinical Monitoring will not be available for Allergens not found in the available list. § If an Allergy is entered utilizing the Other option, the allergy will be highlighted in Yellow to denote that clinical monitoring cannot be provided. · Should the patient report no Allergies or does not have Allergies for a certain Allergy group, select the appropriate option icon. § No Known Allergies § No Known Drug Allergies § No Known Environmental Allergies § No Known Food Allergies © 2013 Computer Programs and Systems, Inc. Medication Reconciliation 37 Chapter 10 Medication Reconciliation 10.1 Overview · Medication Reconciliation is a purchased application. Please contact your CPSI Marketing rep for further details and implementation. · The M/Rec icon is an access portal to the Medication Reconciliation application. Please see the separate user guide for further usage explanation. · If a Patient Account is selected in the traditional ChartLink application, and access is gained to the Physician Problem List or the Physician Documentation applications, the ChartLink 5 application will open. The user may then select the Medication Reconciliation icon located at the top of the ChartLink 5 Icon Bar. The user may also access the Medication Reconciliation application while in CPOE. Select ChartLink 5 Whiteboard > Select Patient Account > Medication Reconciliation Figure 10.1 ChartLink 5 Icon Bar © 2013 Computer Programs and Systems, Inc. 38 ChartLink 5 © 2013 Computer Programs and Systems, Inc. Prescription Entry 39 Chapter 11 Prescription Entry 11.1 Overview · Escribe is a purchased application. Please contact your CPSI Marketing rep for further details and implementation. · The Rx icon is an access portal to the Escribe application. · If a Patient Account is selected in the traditional ChartLink application, and access is gained to the Physician Problem List or the Physician Documentation applications, the ChartLink 5 application will open. The user may select the Prescription Entry icon located at the top of the ChartLink 5 Icon Bar. The user may also access the ChartLink 5 application when accessing the Medication Reconciliation application through CPOE. Select ChartLink 5 Whiteboard > Select Patient Account > Prescription Entry Figure 11.1 ChartLink 5 Icon Bar © 2013 Computer Programs and Systems, Inc. 40 ChartLink 5 © 2013 Computer Programs and Systems, Inc. Immunizations 41 Chapter 12 Immunizations 12.1 Overview This section of the ChartLink 5 user guide will discuss the ability to add and maintain Immunizations to a patient's account. 12.2 Access · The Immz icon is a portal to the Immunization Maintenance Screen. · If a Patient Account is selected in the traditional ChartLink application and access is gained to either the Physician Problem List or Physician Documentation applications, the ChartLink 5 application will open. The user may then select on the Immunizatations icon located at the top of the ChartLink 5 Icon Bar. The user may also access the ChartLink 5 application when accessing the Medication Reconciliation application through CPOE. Select ChartLink 5 Whiteboard > Select Patient Account >Immunizations Figure 12.1 ChartLink 5 Icon Bar 12.3 Immunization Maintenance · A display of the patients complete Immunization record will list upon initial access. § A filter is available to display removed Immunizations. § Filters are also present to determine if user would like to view Current Visit immunizations or immunizations for All Visits. § Select on a column header to arrange the list by desired choice · Select on a listed Immunization to view administration record · If access is gained through one of the Immunization Tables then the Immunization may be found after typing in a search string to begin the search. § When adding a new Immunization it will list all of the CVX codes and will list if the medication is still produced, Active or if no longer available, Inactive. NOTE: Immunizations that are received during the patients hospital or clinic stay will be recorded upon administration via the medication administration module of choice. When an immunization is entered 24 hours after discharge, the user will receive a prompt to indicate that the entered information will be updated in the Person Profile and will display on any future accounts. © 2013 Computer Programs and Systems, Inc. 42 ChartLink 5 Select ChartLink 5 Whiteboard > Select Patient Account > Immunizations > Select Immunization Medication Figure 12.2 Immunization Maintenance · Immunizations recorded through Nursing Medication Administration Modules in Patient © 2013 Computer Programs and Systems, Inc. Immunizations 43 Documentation or MPEMR will contain all fields addressed and editing is not allowed though this application. Editing will need to occur within that certain module. Immunizations entered through the Immunization Table will only contain Immunization Name, Date and Time Received. Date and Time may be edited. Unknown may be entered for Date Received. Time may be left blank. NOTE: The VFC (Vaccines for Children) Program is a federally funded program that provides vaccines at no cost to children who might otherwise not be inoculated due to cost. © 2013 Computer Programs and Systems, Inc. 44 ChartLink 5 © 2013 Computer Programs and Systems, Inc. PACS 45 Chapter 13 PACS 13.1 Overview · The ImageLinkâ PACS - Picture Archiving and Communication System - is a purchased application. Please see your CPSI Marketing Rep for further details and implementation. · Allows the viewing of radiology images. The PACS icon is an access portal to the ImageLink PACS application. Please see the separate user guide for further usage explanation. Select ChartLink 5 Whiteboard > Select Patient Account > PACS Figure 13.1 PACS © 2013 Computer Programs and Systems, Inc. 46 ChartLink 5 © 2013 Computer Programs and Systems, Inc. Order Chronology 47 Chapter 14 Order Chronology 14.1 Overview Order Chronology is an area designed to view orders placed on each patient regardless of the entry point. 14.2 Access The Order Chronology icon is an access portal to the Order Chronology Screen. · If a Patient Account is selected in the traditional ChartLink application and access is gained to either the Physician Problem List or Physician Documentation applications, the ChartLink 5 application will open. The user may then select on the Order Chronology icon located at the top of the ChartLink 5 Icon Bar. The user may also access the ChartLink 5 application when accessing the Medication Reconciliation application through CPOE. Select ChartLink 5 Whiteboard > Select Patient Account > Order Chronology Figure 14.1 14.3 Order Chronology Screen · Display may be filtered § By Active Orders § All Orders · May Group by Department · There is an option to refresh any Order type and Department options. · The orders are listed in Chronological order and completed detail of the order may be viewed in their entirety by selecting on the Order. · Date and Time order was placed will display · Ordering Providers Name will display · Telephone and Verbal Orders will be noted as PO or VO as well as the initials of employee placing the order © 2013 Computer Programs and Systems, Inc. 48 ChartLink 5 Select ChartLink 5 Whiteboard > Select Patient Account > Order Chronology > Select Order Figure 14.2 OrderDetail · The following is a full display of Order Chronology Figure 14.3 Order Chronology © 2013 Computer Programs and Systems, Inc. Transcriptions 49 Chapter 15 Transcriptions This section will discuss Transcriptions that may be found in ChartLink 5. 15.1 Overview Transcription may be selected to display all orders that have a transcription associated to the present hospital stay. 15.2 Access The Transcription Icon may be selected to display all orders that have a transcription associated to the present hospital stay. History and Physicals, O/P Notes, ER notes that are dictated will display. EKG, Radiology and Pathology transcriptions will display as well. · If a Patient Account is selected in the traditional ChartLink application and access is gained to either the Physician Problem List or Physician Documentation applications, the ChartLink 5 application will open. The user may then select on theTranscriptions icon located at the top of the ChartLink 5 Icon Bar. The user may also access the ChartLink 5 application when accessing the Medication Reconciliation application through CPOE. Select ChartLink 5 Whiteboard > Select Patient Account > Transcriptions Figure 15.1 Transcriptions 15.3 Transcriptions Screen · The Screen will display § Ordering Department § Description of Transcription § Date of Transcription § Time of Transcription § Transcription Status § Associated Images § PACS that may be available © 2013 Computer Programs and Systems, Inc. 50 ChartLink 5 Select ChartLink 5 Whiteboard > Select Patient Account > Transcriptions Figure 15.2 Transcriptions · Select on the Transcription description to display the report. Select ChartLink 5 Whiteboard > Select Patient Account > Transcriptions > Select Description Figure 15.3 Radiology Transcription · The Transcription will display for Viewing and may be Exported © 2013 Computer Programs and Systems, Inc. to Adobe Reader. Clinical History 51 Chapter 16 Clinical History 16.1 Overview Clinical History will display transcriptions, lab results, and reports across all accounts and across all departments. 16.2 Access The Clinical History icon will display transcriptions, lab results, and reports across all accounts and across all departments. · If a Patient Account is selected in the traditional ChartLink application and access is gained to either the Physician Problem List or Physician Documentation applications, the ChartLink 5 application will open. The user may then select on the Clinical History icon located at the top of the ChartLink 5 Icon Bar. The user may also access the ChartLink 5 application when accessing the Medication Reconciliation application through CPOE. Select ChartLink 5 Whiteboard > Select Patient Account > Clinical History Figure 16.1 Clinical History 16.3 Clinical History Screen · The Screen will display § Type of Department order § Description of order § Account number that the document was created under. § Date the order was created. § Date of Patient Account Admission. § Date of Patient Account Discharge. § View will be present if an Image is available § PACS will display View if any PACS is available Select ChartLink 5 Whiteboard > Select Patient Account > Clinical History Figure 16.2 Clinical History © 2013 Computer Programs and Systems, Inc. 52 ChartLink 5 · Select on the Description to display the report. Select ChartLink 5 Whiteboard > Select Patient Account > Clinical History > Select Description Figure 16.3 Clinical History Report · The Transcription will display for Viewing and may be Exported to Adobe Reader. © 2013 Computer Programs and Systems, Inc. Attachments 53 Chapter 17 Attachments 17.1 Overview This chapter will discuss the Attachments selection for ChartLink 5. 17.2 Vital Signs This section will discuss the Vital Signs section of Attachments. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Vital Signs Figure 17.1 Vital Signs Graphic I & O The Graphic I & O is a document that includes the patient’s vital signs, weight, diet information, and intake and output charted over a 3-day period. The forms print as “Temporary” until three days of information is completed. After three days, the report prints as “Final” and is a part of the patient’s permanent chart. © 2013 Computer Programs and Systems, Inc. 54 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Vital Signs > Graphic I&O Figure 17.2 Vital Signs-Graphic I & O Data included on the Graphic and I & O form is outlined below: Demographics Box (located upper right-hand corner) · Patient's name · Admitting physician · Age, sex, & room number · Any drug allergies documented through the CPSI system · Medical Record number NOTE: In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. Vital Signs · Each 24-hour period is divided into either two or 4-hour intervals. · Temperature is reflected in a line graph format · Pulse, respiration, and blood pressure are reflected in numeric values below the graph. © 2013 Computer Programs and Systems, Inc. Attachments 55 · Weight, is reflected in pounds or kilograms along with the patient's body-surface area and basic metabolic index. NOTE: An asterisk (*) denotes multiple values have been charted. The first recorded value displays with subsequent values listed in the Patient Progress Notes. Patient Diet & Percent Consumed · Up to three diet entries within a 2- hour period · Diet description, percentage consumed, and time the entry was charted Breast Feeding · Displays for Pediatric and Nursery chart types only. · Prints breast feeding time, minutes and totals for L, R, L/R breast. NOTE: If percentage of diet consumed has been charted on a diet through the MedAct, the Breast Feeding section will not print on the report. © 2013 Computer Programs and Systems, Inc. 56 ChartLink 5 Intake and Output Record · Intake and output volumes reflect totals per shift and a 24-hour total. · Intake and output values charted by frequency display in the top left-hand corner of the boxes. Volume entries display in the center of the box. · Intake displays up to 10 categories. Any entries beyond that will be reflected under "Other" and will be detailed on the Patient Progress Notes. · Output displays up to eight categories. Any entries beyond that will be reflected under "Other" and will be detailed on the Patient Progress Notes. · Option to use eight or 12-hour I&O total in control table. · The following is a full display of the Graphic I & O Report. © 2013 Computer Programs and Systems, Inc. Attachments 57 Graphic and I & O · All reports listed in this section may be Exported format. to Adobe Acrobat Reader © 2013 Computer Programs and Systems, Inc. 58 ChartLink 5 Swan Ganz The Swan Ganz report is a document that includes hemodynamics (CVP, PAP, PAWP, CO, MPAP, SV, SVR, PVR, and CI) information. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Vital Signs > Swan Ganz Figure 17.3 Vital Signs- Swan Ganz Data included on the Swan Ganz Report is outlined below: Demographics Box (located upper right-hand corner) · Patient's name · Admitting physician · Age, sex, & room number · Medical Record number · Any drug allergies documented through the CPSI system NOTE: In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. Entered Values © 2013 Computer Programs and Systems, Inc. Attachments 59 · Date and time the information was charted · Name and title of the person who entered the information displays next to the first entry only. Name and title will not display beside each entry made by that person. · Displays in columns, the following Swan Ganz values that have been entered into the system: § (CVP) Central Venous Pressure § (PAP) Pulmonary Artery Pressure § (PAWP) Pulmonary Artery Wedge Pressure § (CO) Cardiac Output Calculated Values · Displays in columns, the following calculated values which are derived from the charted Swan Ganz values: § (MPAP) Mean Pulmonary Artery Pressure § (MAP) Mean Arterial Pressure § (SV) Stroke Volume § (SVR) Systemic Vascular Resistance § (PVR) Pulmonary Vascular Resistance § (CI) Cardiac Index · The following is a full display of the Swan Ganz Report. © 2013 Computer Programs and Systems, Inc. 60 ChartLink 5 Swan Ganz · All reports listed in this section may be Exported © 2013 Computer Programs and Systems, Inc. to Adobe Acrobat Reader format. Attachments 61 O2 Sat Bar Graph The O2 Sat Bar Graph is a document that displays the O2LM, FiO2, and O2SAT, which is graphed and includes the method of delivery. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Vital Signs > O2 Saturation Bar Graph Figure 17.4 Vital Signs - O2 Saturation Graph Data included in the O2 Sat Bar Graph is outlined below: Demographics box (located upper right-hand corner) · Patient’s name · Account number · Admitting physician · Age, sex, and room number · Medical Record number · Any drug allergies documented through the CPSI System O2 Information · O2 L/M, FiO2, and O2 Sat values display numerically © 2013 Computer Programs and Systems, Inc. 62 ChartLink 5 · O2 Sat values display as a bar graph · O2 Sat values display on the bar graph along with the method · The following is a full display of the O2 Sat Bar Graph. © 2013 Computer Programs and Systems, Inc. Attachments 63 O2 Saturation Bar Graph · All reports listed in this section may be Exported to Adobe Acrobat Reader format. Critical Care Flow Sheet The Critical Care Flow Sheet is a document that includes specific patient information charted within the 8-hour time frame. The report provides details of the patient’s condition and plan of care © 2013 Computer Programs and Systems, Inc. 64 ChartLink 5 and may also be used to track trends in the patient’s progress. It is primarily used in the ICU. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Vital Signs > Critical Care Flow Sheet Figure 17.5 Vital Signs - Critical Care Flow Sheet Data included on the Critical Care Flow Sheet is outlined below: Demographics Box (located upper right-hand corner) · Patient's name · Account number · Admitting physician · Age, sex, & room number · Medical Records number · Any drug allergies documented through the CPSI System Vital Signs · Pulse and blood pressure display graphically in 15-minute intervals. · Temperature and respirations display numerically in 15-minute intervals. Hemodynamics © 2013 Computer Programs and Systems, Inc. Attachments 65 CVP, PAP, PAWP, and CO/CI values display in 1-hour intervals. Ventilation Mechanics (Optional) · Nursing Administration determines which seven out of twelve options will display. · Values display in 1-hour intervals. Intake (Optional) · Nursing Administration determines which four out of twelve options will display. · Values display in 1-hour intervals. · The "OTHER" box combines all intake values not specified on the flow sheet which may be seen in detail in the Patient Progress Notes. Output (Optional) · Nursing Administration determines which four out of eighteen options will display. · Values display in one hour intervals. · The "OTHER" box combines all output values not specified on the flow sheet, which may be seen in detail in the Patient Progress Notes. · Entries charted by frequency, display in the top left corner of the boxes where volume entries also display. NOTE: An asterisk (*) adjacent to any value on this flow sheet denotes multiple values have been charted. The first recorded value displays, with subsequent values listed in the Patient Progress Notes. Medications · Medications administered during the selected time frame · Date and time of last administration · Medication description · Location of administration or reason if it is a PRN · Dosage Neuro checks · Neuro checks charted through the VS application since last locked shift · Date and time information was entered © 2013 Computer Programs and Systems, Inc. 66 ChartLink 5 · Name and title of person who charted the entry Distinctive Nursing Assessments · Assessments charted in the eight hour period covered, that are flagged as distinctive and should be noted by the nursing staff · Date and time of entry · In order for this information to be reflected, it must be set up by Nursing Administration. Distinctive Physical Assessments · Assessments charted in the 8-hour period covered that are flagged as distinctive and should be noted by the medical staff · Date and time of entry · The following is a full display of the Critical Care Flow Sheet. © 2013 Computer Programs and Systems, Inc. Attachments 67 Critical Care Flow Sheet · All reports listed in this section may be Exported to Adobe Acrobat Reader format. All Critical Care Flowsheets The Critical Care Flow Sheet is a document that includes specific patient information charted within the 8-hour time frame. The report provides details of the patient’s condition and plan of care and can also be used to track trends in the patient’s progress. It is primarily used in the ICU. © 2013 Computer Programs and Systems, Inc. 68 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Vital Signs > All Critical Care Flow Sheet Figure 17.6 Vital Signs - All Critical Care Flow Sheet Data included on the All Critical Care Flow Sheet is outlined below: Demographics Box (located upper right-hand corner) · Patient's name · Account number · Admitting physician · Age, sex, & room number · Medical Records number · Any drug allergies documented through the CPSI System Vital Signs · Pulse and blood pressure display graphically in 15 minute intervals. · Temperature and respirations display numerically in 15 minute intervals. Hemodynamics CVP, PAP, PAWP, and CO/CI values display in one hour intervals. © 2013 Computer Programs and Systems, Inc. Attachments 69 Ventilation Mechanics (Optional) · Nursing Administration determines which seven out of twelve options will display. · Values display in 1-hour intervals. Intake (Optional) · Nursing Administration determines which four out of twelve options will display. · Values display in 1-hour intervals. · The "OTHER" box combines all intake values not specified on the flow sheet, which can be seen in detail in the Patient Progress Notes. Output (Optional) · Nursing Administration determines which four out of eighteen options will display. · Values display in one hour intervals. · The "OTHER" box combines all output values not specified on the flow sheet, which can be seen in detail in the Patient Progress Notes. · Entries charted by frequency display in the top left corner of the boxes where volume entries also display. NOTE: An asterisk (*) adjacent to any value on this flow sheet denotes multiple values have been charted. The first recorded value displays, with subsequent values listed in the Patient Progress Notes. Medications · Medications administered during the selected time frame · Date and time of last administration · Medication description · Location of administration, or reason if it is a PRN · Dosage Neuro checks · Neuro checks charted through the VS application since last locked shift · Date and time information was entered · Name and title of person who charted the entry © 2013 Computer Programs and Systems, Inc. 70 ChartLink 5 Distinctive Nursing Assessments · Assessments charted in the 8-hour period covered, that are flagged as distinctive and should be noted by the nursing staff · Date and time of entry · In order for this information to be reflected, it must be set up by Nursing Administration. Distinctive Physical Assessments · Assessments charted in the 8-hour period covered, that are flagged as distinctive and should be noted by the medical staff · Date and time of entry · The Critical Care Flowsheet for the last eight hours will appear on the screen. Use the scroll bar or the page selector to access additional information for the last 24 hours. · To view previous days Critical Care Flowsheets select the date from the lower section of the split screen. · The following is a full display of the Critical Care Flow Sheet. © 2013 Computer Programs and Systems, Inc. Attachments 71 All Critical Care Flow Sheets · All reports listed in this section may be Exported to Adobe Acrobat Reader format. Growth Charts Various Growth Charts are available depending upon the patient's age range and gender. Weight and height must be present on the account in order for the growth charts to be accessible. Physicians will have the ability to view historical growth charts: all charts from birth through the current age. Additionally, two different growth charts (5th to 95th Percentile and 3rd to 97th Percentile) are selectable, either for the current age or to include historical weight and height entries. Data included on the Growth Charts is outlined below: Birth to 36 Months · 5 - 95 Percentile Length and Weight Growth Chart for the sex of the patient 3 - 97 Percentile Length and Weight Growth Chart for the sex of the patient © 2013 Computer Programs and Systems, Inc. 72 ChartLink 5 2 Years to 5 Years · Weight for Stature Growth Chart for the sex of the patient 2 Years to 20 Years · 5 - 95 Percentile Stature Growth Chart for the sex of the patient · 5 - 95 Percentile BMI Growth Chart for the sex of the patient · 3 - 97 Percentile Stature Growth Chart for the sex of the patient · 3 - 97 Percentile BMI Growth Chart · The following is a full display of a Growth Chart. © 2013 Computer Programs and Systems, Inc. Attachments 73 Growth Chart · All reports listed in this section may be Exported to Adobe Acrobat Reader format. © 2013 Computer Programs and Systems, Inc. 74 ChartLink 5 Attachments · The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that have been assigned to this section. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Vital Signs > Attachments Figure 17.7 Vital Signs - Attachments · Data located in Attachments · Deleted Items will display © 2013 Computer Programs and Systems, Inc. Attachments 75 Figure 17.8 Vital Signs - Attachments · Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms User Guide. · 17.3 will display if data is not present in this area to be viewed. Medical Records This section will discuss the Medical Records section of Attachments. © 2013 Computer Programs and Systems, Inc. 76 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Medical Records Figure 17.9 Medical Rcords Overview The Medical Records section will display any scanned images for the patient account. © 2013 Computer Programs and Systems, Inc. Attachments 77 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Med Rec > Attachments Figure 17.10 Medical Records Attachments · The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that have been assigned to this section. © 2013 Computer Programs and Systems, Inc. 78 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Med Rec > Attachments Figure 17.11 Medical Records - Attachments · Data located in Attachments · Deleted Items will display © 2013 Computer Programs and Systems, Inc. Attachments 79 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Med Rec > Attachments Figure 17.12 Medical Records - Attachments · Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms User Guide. will display if data is not present in this area to be viewed. · 17.4 Orders This section will discuss the Orders section of Attachments. © 2013 Computer Programs and Systems, Inc. 80 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Orders Figure 17.13 Orders Physician's Nursing Order Report The Physician's Nursing Order Sheet is a document that includes the patient’s verified nursing orders (CPOE and orders placed via ClientWare). Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Orders Figure 17.14 Orders © 2013 Computer Programs and Systems, Inc. Attachments 81 Demographics Box (located upper right-hand corner) · Patient's name · Admitting physician · Age, sex, and room number · Any drug allergies documented through the CPSI system NOTE: In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. Nursing Order Box Shaded in gray, each box contains one nursing order of up to 75 characters Nursing Order Comment Displays any comment that was added, the last time the order was addressed by the nursing staff. Nursing Order Status · Appears directly below the comment · The status indicates the last action taken on an order · The date and time will indicate the last time the order was addressed · Displays initials of the person who charted the nursing order Additional Notes · Unverified nursing orders will NOT be included in this report · Nursing orders discontinued within eight hours of the printing of this report, will be included. · The following is a full display of the Physician's Nursing Order Sheet © 2013 Computer Programs and Systems, Inc. 82 ChartLink 5 Physician's Nursing Order Sheet Attachments · The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that have been assigned to this section. © 2013 Computer Programs and Systems, Inc. Attachments 83 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Med Rec > Attachments Figure 17.15 Orders - Attachments · Data located in Attachments · Deleted Items will display © 2013 Computer Programs and Systems, Inc. 84 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Orders > Attachments Figure 17.16 Orders - Attachments · Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms User Guide. will display if data is not present in this area to be viewed. · 17.5 Laboratory This section will discuss the process of reviewing Laboratory orders, results and reports. © 2013 Computer Programs and Systems, Inc. Attachments 85 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Laboratory Figure 17.17 Laboratory Comparative All - This Stay The comparative vertical report is an update of all test results for a patient account. The report is a comparative summary presentation of all data with test names along the vertical axis and results listed chronologically along a horizontal axis. Collection dates and times are printed on the horizontal axis. Up to seven events will print per row with subsequent results wrapping below the most current results. Scroll to view all available reports related to this hospital stay. © 2013 Computer Programs and Systems, Inc. 86 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Comparative All This Stay Figure 17.18 Comparative All-This Stay · The following is a full display of the Critical Care Flow Sheet. © 2013 Computer Programs and Systems, Inc. Attachments 87 Critical Care Flow Sheet · The Comparative All – This Stay and all the other laboratory reports listed in this section will display in Adobe Acrobat Reader format. © 2013 Computer Programs and Systems, Inc. 88 ChartLink 5 Comparative/Department - This Stay · This option will display a columnar version of the patient results by the sub-department of the laboratory for a single account. Select ChartLink 5 Whiteboard Comparative/Department - This Stay > select Patient Account > Attachments Figure 17.19 Comparative/Department-This Stay · The following is a full display of the Comparative By Dept – This Stay report. © 2013 Computer Programs and Systems, Inc. icon > Attachments 89 Comparative By Dept – This Stay © 2013 Computer Programs and Systems, Inc. 90 · ChartLink 5 The Comparative By Dept-This Stay and all the other laboratory reports listed in this section will display in Adobe Acrobat Reader format. Comparative - All Stays · This option allows access to comparative results for more than one stay. Select ChartLink 5 Whiteboard Comparative/Department - All Stay > select Patient Account > Figure 17.20 Comparative -All Stays · The following is a full display of the Comparative - All Stays report. © 2013 Computer Programs and Systems, Inc. Attachments icon > Attachments 91 Comparative - All Stays © 2013 Computer Programs and Systems, Inc. 92 ChartLink 5 Comparative/Departments - All Stays · This option will display a columnar version of the patient results by the sub-department of the laboratory for more than one stay. Select ChartLink 5 Whiteboard Comparative/Department - All Stay > select Patient Account > Attachments Figure 17.21 Comparative/Department-All Stay · The following is a full display of the Comparative By Dept – All Stay report. © 2013 Computer Programs and Systems, Inc. icon > Attachments 93 Comparative By Dept – All Stay · The Comparative By Dept-All Stay and all the other laboratory reports listed in this section will display in Adobe Acrobat Reader format. © 2013 Computer Programs and Systems, Inc. 94 ChartLink 5 Comparative - Multifacility · This option allows access to comparative results from all associated Multifacility locations. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Comparative Multifacility Figure 17.22 Comparative - Multifacility · The following is a full display of the Comparative- Multifacility report © 2013 Computer Programs and Systems, Inc. Attachments 95 Comparative- Multifacility Detail Report · This option allows access to a detail report of all laboratory results for this patient account. © 2013 Computer Programs and Systems, Inc. 96 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Detailed Report Figure 17.23 Detail Report · The following is a full display of the Detail Report. © 2013 Computer Programs and Systems, Inc. Attachments 97 Detail Report © 2013 Computer Programs and Systems, Inc. 98 ChartLink 5 Attachments · The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that have been assigned to this section. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Laboratory > Attachments Figure 17.24 Laboratory - Attachments · Data located in Attachments · Deleted Items will display © 2013 Computer Programs and Systems, Inc. Attachments 99 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Laboratory > Attachments Figure 17.25 Laboratory - Attachments · Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms User Guide. will display if data is not present in this area to be viewed. · 17.6 Medication This section will discuss the process of reviewing Medication reports. © 2013 Computer Programs and Systems, Inc. 100 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Medication Figure 17.26 Medication MAR Final The MAR-Final is a document that includes the patient’s complete medication administration record. © 2013 Computer Programs and Systems, Inc. Attachments 101 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Medication Figure 17.27 MAR Final The previous 24 hours of Medication documentation display is based on one of the following time periods determined by administration: 0700 – 0659, 1500 – 1459 or 2300 – 2259. The medications are grouped by categories (X1, Scheduled/Routine, IV orders, and PRN) and display in the order that they were entered into the system. The previous 24-hours display in eight-hour time periods, with the medication administration time(s), the initials of the nurse who administered the medication, and the actual time the medication was administered appearing below the initials. · All continuous IVs that were ordered, scheduled, administered or discontinued during the 24-hour period are covered by the report · Start date, stop date if applicable, stop code if applicable, and "Unverified" if the IV has not been verified · Medication description, flow rate, frequency, and components · Initials of the person who administered the IV or a "G" (Given) will appear under the appropriate hour of the 8-hour block. · The following is a full display of the MAR Final report. © 2013 Computer Programs and Systems, Inc. 102 ChartLink 5 MAR Final © 2013 Computer Programs and Systems, Inc. Attachments 103 · The MAR Final report and the other reports listed in this section will display in Adobe Acrobat Reader format. Demographics Box · Patient's name · Admitting physician · Age, sex, & room number · Drug allergies documented through the CPSI system · In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. Figure 17.28 MAR Final Report Demographics Box One Time Orders · All X1 medications that were ordered, scheduled, administered or discontinued during the 24-hour period are covered by the report · Start and stop date, stop code and "Unverified" if the medication has not been verified · Medication description, dosage, frequency, and instructions · Scheduled time appears under the appropriate hour of the 8- hour block. · Initials of the person who administered the medication or "G" (Given) will appear under the appropriate hour of the 8-hour block. © 2013 Computer Programs and Systems, Inc. 104 ChartLink 5 Figure 17.29 MAR Final One Time Orders Scheduled/Routine Medications · All routine medications that were ordered, scheduled, administered or discontinued during the 24-hour period covered by the report · Start date, stop date if applicable, stop code if applicable and "Unverified" if the medication has not been verified · Medication description, dosage, frequency, & instructions · Components and flow rate on piggybacks · Scheduled time appears under the appropriate hour of the 8-hour block. · Initials of the person who administered the medication or "G" (Given) will appear under the appropriate hour of the 8-hour block. © 2013 Computer Programs and Systems, Inc. Attachments 105 © 2013 Computer Programs and Systems, Inc. 106 ChartLink 5 IV Orders · All continuous IVs that were ordered, scheduled, administered or discontinued during the 24-hour period and covered by the report · Start date, stop date if applicable, stop code if applicable, and "Unverified" if the IV has not been verified · Medication description, flow rate, frequency, and components · Initials of the person who administered the IV or a "G" (Given) will appear under the appropriate hour of the 8-hour block. Figure 17.30 MAR Final IV Orders MAR Temporary The MAR - Temporary is a document that includes the patient’s medication administration record for the current 24 hours. © 2013 Computer Programs and Systems, Inc. Attachments 107 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Medication > MAR Temporary Figure 17.31 MAR Temporary The MAR - Temporary is a document that includes the patient’s medication administration record for the current 24 hours, based on one of the following time periods determined by nursing administration: 0700 – 0659, 1500 – 1459 or 2300 – 2259. The medications are grouped by categories (X1, Scheduled/Routine, IV orders and PRN) and display in the order that they were entered into the system. The 24 hour displays in eight-hour time periods, with the medication administration time(s), the initials of the nurse who administered the medication, and the actual time the medication was administered appearing below the initials. · The following is a full display of the MAR Temporary report. © 2013 Computer Programs and Systems, Inc. 108 ChartLink 5 MAR Temporary © 2013 Computer Programs and Systems, Inc. Attachments 109 Demographics Box · Patient's name · Admitting physician · Age, sex, & room number · Drug allergies documented through the CPSI system · In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. Figure 17.32 MAR Temporary Report Demographics Box One Time Orders · All X1 medications that were ordered, scheduled, administered or discontinued during the 24-hour period are covered by the report · Start and stop date, stop code and "Unverified" if the medication has not been verified · Medication description, dosage, frequency, and instructions · Scheduled time appears under the appropriate hour of the 8- hour block. · Initials of the person who administered the medication or "G" (Given) will appear under the appropriate hour of the 8-hour block. Figure 17.33 MAR Temporary One Time Orders © 2013 Computer Programs and Systems, Inc. 110 ChartLink 5 Scheduled/Routine Medications · All routine medications that were ordered, scheduled, administered or discontinued during the 24-hour period covered by the report · Start date, stop date if applicable, stop code if applicable and "Unverified" if the medication has not been verified · Medication description, dosage, frequency, & instructions · Components and flow rate on piggybacks · Scheduled time appears under the appropriate hour of the 8-hour block. · Initials of the person who administered the medication or "G" (Given) will appear under the appropriate hour of the 8-hour block. © 2013 Computer Programs and Systems, Inc. Attachments 111 © 2013 Computer Programs and Systems, Inc. 112 ChartLink 5 IV Orders · All continuous IVs that were ordered, scheduled, administered or discontinued during the 24-hour period are covered by the report · Start date, stop date if applicable, stop code if applicable, and "Unverified" if the IV has not been verified · Medication description, flow rate, frequency, and components · Initials of the person who administered the IV or a "G" (Given) will appear under the appropriate hour of the 8-hour block. Figure 17.34 MAR Temporary IV Orders PRN Medications · All PRN medications that were ordered, administered or discontinued during the 24 hour period are covered by the report · Start date, stop date if applicable, stop code if applicable, and "Unverified" if the medication has not been verified · Medication description, dosage, frequency, and instructions · Initials of the person who administered the medication or a "G" (Given) will appear under the appropriate hour of the 8-hour block. © 2013 Computer Programs and Systems, Inc. Attachments 113 Figure 17.35 MAR Temporary PRN Medications All MARs The All MAR - is an area that includes the patient’s medication administration record for 24 hour time periods · The desired date may be selected from the lower section of the split screen for display. © 2013 Computer Programs and Systems, Inc. 114 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Medication > All MARs Figure 17.36 All MARs 24 hours of Medication documentation display is based on one of the following time periods determined by administration: 0700 – 0659, 1500 – 1459 or 2300 – 2259. The medications are grouped by categories (X1, Scheduled/Routine, IV orders, and PRN) and display in the order that they were entered into the system. The previous 24-hours display in eight-hour time periods, with the medication administration time(s), the initials of the nurse who administered the medication, and the actual time the medication was administered appearing below the initials. · All continuous IVs that were ordered, scheduled, administered or discontinued during the 24-hour period are covered by the report · Start date, stop date if applicable, stop code if applicable, and "Unverified" if the IV has not been verified · Medication description, flow rate, frequency, and components · Initials of the person who administered the IV or a "G" (Given) will appear under the appropriate hour of the 8-hour block. · The following is a full display of the All MARs report. © 2013 Computer Programs and Systems, Inc. Attachments 115 All MARs All 5 Day MARs From ChartLink 5 it is possible to display the Temporary and/or Final 5-Day MAR from each day of the selected patient’s stay. © 2013 Computer Programs and Systems, Inc. 116 ChartLink 5 · Select the desired date from the bottom of the split screen to display the 5-Day MAR for that date. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Medication > All 5 Day MARs Figure 17.37 All 5 Day MARs 24 hours of Medication documentation display is based on one of the following time periods determined by administration: 0700 – 0659, 1500 – 1459 or 2300 – 2259. The medications are grouped by categories (X1, Scheduled/Routine, IV orders, and PRN) and display in the order that they were entered into the system. The previous 24-hours display in eight-hour time periods, with the medication administration time(s), the initials of the nurse who administered the medication, and the actual time the medication was administered appearing below the initials. · All continuous IVs that were ordered, scheduled, administered or discontinued during the 24-hour period are covered by the report · Start date, stop date if applicable, stop code if applicable, and "Unverified" if the IV has not been verified · Medication description, flow rate, frequency, and components · Initials of the person who administered the IV or a "G" (Given) will appear under the appropriate hour of the 8-hour block. · The following is a full display of the All 5 Day report. © 2013 Computer Programs and Systems, Inc. Attachments 117 All 5 Day © 2013 Computer Programs and Systems, Inc. 118 ChartLink 5 Scheduled Medications The Scheduled Medications report is a document that includes all of the current scheduled medications for an eight-hour time period for an individual patient or group of patients. PRNs and large volume IVs do not print on the report. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Medication > Scheduled Medications Figure 17.38 Scheduled Medications Data included on the Scheduled Medication Report is outlined below: · Patient Information § Patient's name § Room number § Age § Sex § Attending Physician § Any drug allergies documented through the CPSI System · Medication Information § Medication description, dosage, frequency, instructions § "Unverified" if the medication has not been verified § Flow rate and components on IV Piggybacks · Omission Information § Date, time, and reason medication was omitted § Check time which indicates that a medication was not administered within thirty minutes before or 30 minutes after the scheduled time © 2013 Computer Programs and Systems, Inc. Attachments 119 · Administration Schedule § An eight-hour time frame prints beside the Omission Information section. § Indicates the scheduled time for each medication § A "G" (Given) displays below the appropriate time, indicating when the medication was given. · The following is a full display of the Scheduled Medications report. © 2013 Computer Programs and Systems, Inc. 120 ChartLink 5 Scheduled Medications © 2013 Computer Programs and Systems, Inc. Attachments 121 PCA The following section will describe the PCA order entry and the PCA Infusion form. PCA Infusion Form The PCA Infusion Form is a comparative document that includes the patient’s PCA administration chart and assessment from the beginning of stay. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Medication >PCA Figure 17.39 PCA Data included on the PCA Infusion Form is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § Admitting physician § Age, sex, & room number § Medical Records number § Any drug allergies documented through the CPSI system · Medication: The PCA medication description will be highlighted in a gray box. · Protocol § Date and time protocol was entered § Continuous infusion rate (Optional) § Name & title of person who entered the protocol © 2013 Computer Programs and Systems, Inc. 122 § § § § § ChartLink 5 Lock-out time Bolus / loading dose Four-hour limit Patient administration dose Initial syringe volume · The following is a full display of the PCA form. PCA Medication Record The Medication Record Report is a document that includes all ordered medications for an individual patient. © 2013 Computer Programs and Systems, Inc. Attachments 123 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Medication > Medication Record Figure17.40 Medication Record Report Data included on the Patient Drug Information sheet is outlined below: · Patient Information § Patient's name § Room number § Age § Sex § Attending Physician § Drug allergies documented through the CPSI System · Medication Information § Medication description, dosage, frequency, route, and instructions § Start/Stop information § Flow rate and components on IV Piggybacks · Omission Information § Date, time, and reason medication was omitted · Administration Record § Date/Time § Nurse § Dose/Unit § Site § Comments/Reason · The following is a full display of the Medication Record Report. © 2013 Computer Programs and Systems, Inc. 124 ChartLink 5 Medication Record Report © 2013 Computer Programs and Systems, Inc. Attachments 125 Medication Reconciliation Report This report can be used to track a patient's medications from admit to discharge or transfer to another care giver or facility. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Medication > Medication Reconciliation Report Figure 17.41 Medication Reconciliation Report The Medication Reconciliation report will display all medications. The "Home Medications" taken during the Point of Care Initial Interview will be at the beginning of the report followed by a page break. The following pages will present the patients hospital medications. A Continue/Discontinue option for both home and hospital medications will be included beside medication descriptions. The physician will have a section on the report for additional medications. NOTE: This is a displayed report. It is not interactive. Data included on the MEDICATION RECONCILIATION REPORT is outlined below: · Patient Information § Patient's name § Account Number § Age § Sex § Room Number § Medical Record Number § Attending Physician § Consulting Physician © 2013 Computer Programs and Systems, Inc. 126 ChartLink 5 § Diagnosis § Height, Weight, BAS § Any drug allergies documented through the CPSI System · Medication Information § Medication description, dosage, frequency, route, and instructions § Start/Stop information, including the stop codes § Flow rate and components on IV Piggybacks § PCA Medications and protocol § Diabetic Record Medication and sliding scale § The option to continue or discontinue the medication NOTE: “Med continued on the next page” will print at the bottom of the page if information continues to the next page. “Med is continued from previous page” will print at the top of the subsequent page. · The following is an example of the Medication Reconciliation Report. © 2013 Computer Programs and Systems, Inc. Attachments 127 Medication Reconciliation Report Attachments · The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that have been assigned to this section. © 2013 Computer Programs and Systems, Inc. 128 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon >Medication > Attachments Figure 17.42 Medications - Attachments · Data located in Attachments · Deleted Items will display © 2013 Computer Programs and Systems, Inc. Attachments 129 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon >Medications > Attachments Figure 17.43 Medications - Attachments · Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms User Guide. will display if data is not present in this area to be viewed. · 17.7 Radiology This section will discuss the Radiology Transcriptions © 2013 Computer Programs and Systems, Inc. ChartLink 5 130 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Radiology Figure 17.44 Radiology Overview Radiology Transcriptions may be viewed from theTranscriptions 5 Icon Bar. 17.8 49 Icon located on the ChartLink Multi Disciplinary This section of the ChartLink 5 User Guide will discuss Multi Disciplinary documentation. © 2013 Computer Programs and Systems, Inc. Attachments 131 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Multi Disciplinary Figure 17.45 Multi Disciplinary Discharge Planner The Discharge Planner is a document that includes financial and environmental concerns, expectations for discharge, potential for activities of daily living, etc. for the patient. © 2013 Computer Programs and Systems, Inc. 132 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Multi Disciplinary > Discharge Planner Figure 17.46 Discharge Planner Data included on the Discharge Planner is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § Admitting Physician § Age, sex, & room number § Medical Record number § Drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. · Discharge Planner § Up to 50 hospital-defined questions that can be answered to document a plan for the patient's discharge § The questions appear in bold text with the responses listed below. § Once charted, the date, time, name, and title of the person who charted the information will be reflected. · Signature Line § A signature line is provided in lower right-hand corner of the report. · The Discharge Planner report and the other reports listed in this section will display in Adobe Acrobat Reader format. · The following is a full display of the Discharge Planner report. © 2013 Computer Programs and Systems, Inc. Attachments 133 Discharge Planner Problem List The Problem List is a document that includes the patient’s identified problems and goals and the current status of each. It can be used as a reference for the latest activity charted without having © 2013 Computer Programs and Systems, Inc. 134 ChartLink 5 to review the Patient Progress Notes. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Multi Disciplinary > Problem List Figure 17.47 Problem List Data included on the Problem List Report is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § Admitting physician § Age, sex, & room number § Medical Record number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. · Problem List Box § Shaded in gray, each box contains one problem order of up to 75 characters. · Problem List Activity § Displays last action taken to the problem and any comment that was added § Next to the action it will display the date, time, and name of person entering the information § Below the Problem and Action to the problem the goals related to that problem will be listed in order of entry and will be preceded with an asterisk § Below all goals, report will display last action taken and any comments § Next to all goals it will display the date, time, and name of person entering the information · Problem List Status © 2013 Computer Programs and Systems, Inc. Attachments § § § § 135 The status indicates the last action taken on the problem Appears directly below the comment The date and time will indicate the last time the problem was charted on Displays name and title of the person who charted on the problem or goals · Additional Notes § Problems that have been resolved will display on this report · The following is a full display of the Problem List report. © 2013 Computer Programs and Systems, Inc. 136 ChartLink 5 Problem List © 2013 Computer Programs and Systems, Inc. Attachments 137 Problem Activities The Problem Activity report is a document that includes the patient’s identified problems and goals and all activity charted on each. It displays the path of progression toward resolution from the beginning of stay. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Multi Disciplinary > Problem Activities Figure 17.48 Problem Activities Data included on the Problem Activity Report is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § Admitting physician § Age, sex, & room number § Medical Record number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. · Problem List Box § Shaded in gray, each box contains one problem order of up to seventy-five characters · Problem Activity § Just below the problem box will be list of goals with date, time, and name of person who entered the information § Following the goals will be the action taken related to the problem contained in a box § All goals and goal activity will follow the last action to the problem box in chronological order © 2013 Computer Programs and Systems, Inc. 138 ChartLink 5 § All entries will be preceded by the date, time, and name of person who entered the information § The last action taken will appear in bold with comments listed below · Problem List Status § The status indicates the last action taken on the problem § Appears directly above the comment § The date and time will indicate the last time the problem was charted on § Displays name and title of the person who charted on the problem or goals NOTE: Problems that have been resolved will display on this report The following is a full display of the Problem Activities report. © 2013 Computer Programs and Systems, Inc. Attachments 139 Problem Activities © 2013 Computer Programs and Systems, Inc. 140 ChartLink 5 Care Plan The Care Plan is a document that includes information regarding the patient’s plan of care. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Multi Disciplinary > Care Plan Figure 17.49 Care Plan Data included on the Care Plan is outlined below: · Demographics box (located upper right-hand corner) § Patient’s name § Account number § Admitting physician § Age, sex, and room number § Any drug allergies documented through the CPSI System · Medical Diagnosis and definition · Nursing Diagnosis · Goals · Interventions · Evaluation column · The following is a full display of the Care Plan report. © 2013 Computer Programs and Systems, Inc. Attachments 141 Care Plan © 2013 Computer Programs and Systems, Inc. 142 ChartLink 5 Discharge Summary The Discharge Summary is a document that includes the patient’s diet, current medications, other instructions, and any other information pertinent to the patient’s discharge status. It is part of the patient’s permanent chart. The Discharge Instructions are included in the Discharge Summary. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Multi Disciplinary > Discharge Summary Figure 17.50 Discharge Summary Data included on the Discharge Summary is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § Admitting physician § Age, sex, & room number § Medical Record number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number, and page number will appear along the bottom edge of the page. · Diet: The patient's diet will display in the top left-hand corner of the report just below the header, preceded by the date, time, name and title of the person who charted the information. · Medications § Description of the medications the patient is taking home § Dosage, frequency, and instructions § Date and time of last administration © 2013 Computer Programs and Systems, Inc. Attachments 143 · Other Instructions § Up to 30 hospital-defined questions that can be answered to detail the instructions given to the patient § The questions appear in bold text with the responses listed below. § Once charted, the date, time, name, and title of the person who charted the information will be reflected. § This section of instructions also prints on the Discharge Instructions report. · Other Information § Up to thirty hospital-defined questions can be answered to describe other pertinent patient information § The questions appear in bold text with the responses listed below. § Once charted, the date, time, name, and title of the person who charted the information will be reflected. § This section of information will ONLY print on the Discharge Summary report. · Signature Lines: Signature lines are located at the bottom of the report for the patient and the nurse providing the care. · The following is a full display of the Discharge Summary report. © 2013 Computer Programs and Systems, Inc. 144 ChartLink 5 Discharge Summary Discharge Instructions The Discharge Instructions is a document that includes the patient’s diet, current medications and any other instructions pertinent to the patient’s discharge status. The Discharge Instructions are included in the Discharge Summary. © 2013 Computer Programs and Systems, Inc. Attachments 145 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Multi Disciplinary > Discharge Instructions Figure 17.51 Discharge Instructions Data included on the Discharge Instructions is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § Admitting physician § Age, sex, & room number § Medical Records number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. · Diet: The patient's diet will display in the top left-hand corner of the report just below the header. · Medications § Description of the medications the patient is taking home § Dosage, frequency, instructions § Date and time of last administration · Other Instructions § Up to 30 hospital-defined questions that can be answered to detail the instructions given to the patient § The questions appear in bold text with the responses listed below. § Once charted, the date, time, name, and title of the person who charted the information will be reflected. § This section of instructions also prints on the Discharge Summary report. © 2013 Computer Programs and Systems, Inc. 146 ChartLink 5 · Signature Lines: Signature lines are located at the bottom of the report, for the patient and the nurse providing the care. · The following is a full display of the Discharge Instructions report. © 2013 Computer Programs and Systems, Inc. Attachments 147 Discharge Instructions Transfer Form The Patient Transfer Form is a document that includes the patient’s demographics, transferring and receiving facilities, medical information, active pharmacy orders, transfer consent, request or refusal, and other information pertinent for the transfer process. © 2013 Computer Programs and Systems, Inc. 148 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Multi Disciplinary > Transfer Form Figure 17.52 Transfer Form Data included on the Patient Transfer Form is outlined below: · Patient Demographic Information § Patient's name, address, sex, birth date and religion § Insurance company, policy number and address § Dates of admission, discharge and transfer § Facility transferring FROM and TO § In addition to the above mentioned information, a single line containing the patient's name, medical record number, account number, age, sex, room number and page number will appear along the bottom edge of the page. Patient Medical Information Displays the most recent: · Temperature · Pulse · Respirations · Blood pressure · Height and weight · Diet · Allergies · Oxygen Saturation · Oxygen Delivery · The following is a full display of the Transfer Form report. © 2013 Computer Programs and Systems, Inc. Attachments 149 Transfer Form © 2013 Computer Programs and Systems, Inc. 150 ChartLink 5 Initial Interview The Initial Interview is a document that includes information regarding the patient’s demographics, pertinent history, and discharge planning. · Select the multidisciplinary chart type from the lower split screen to display the desired Initial Interview. © 2013 Computer Programs and Systems, Inc. Attachments 151 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Multi Disciplinary > Initial Interview Figure 17.53 Initial Interview The Initial Interview is a document that includes information regarding the patient’s demographics, pertinent history, and discharge planning. Data included on the Initial Interview is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § The admitting physician § Age, sex, & room number § Medical Record number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. Patient Information Box Patient's name Name (person to contact in an emergency) Birth date and age Relation (of above person) Sex Address Marital status Phone Occupation Attending physician Religion Consulting physician Admitting diagnosis · The following is a full display of the Initial Interview report. © 2013 Computer Programs and Systems, Inc. 152 ChartLink 5 Initial Interview Initial Physical Assessment The Initial Physical Assessment is a document that includes information regarding the patient’s initial vital signs and assessment of body systems. · Select the multidisciplinary chart type from the lower split screen to display the desired Initial Physical Assessment. © 2013 Computer Programs and Systems, Inc. Attachments 153 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Multi Disciplinary > Initial Physical Assessment Figure 17.54 Initial Physical Assessment Data included on the Initial Physical Assessment Report is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § Admitting physician § Age, sex, & room number § Medical Record number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. · Initial Vital Signs § Temperature (including site) § Pulse (including site) § Respiration § Blood Pressure (including posture and extremity) § Weight § The date, time, name and title of the person who charted the information. Assessment Categories Each assessment will be preceded by the appropriate heading below: § Metabolic/Integument § Pulmonary § Cardiovascular § Gastrointestinal § Genitourinary § Reproductive © 2013 Computer Programs and Systems, Inc. 154 ChartLink 5 § Musculoskeletal § Neurological § Injury Risk § Pain § Psychosocial § Intravenous § Wound · The following is a full display of the Initial Physical Assessment report. © 2013 Computer Programs and Systems, Inc. Attachments 155 Initial Physical Assessment report Patient Progress Notes The Patient Progress Notes is a document that includes information from most POC applications charted during a given time frame. The Initial Interview and Initial Physical Assessment are not included in the Patient Progress Notes. · Select the date from the lower split screen to display the desired Patient Progress Note. © 2013 Computer Programs and Systems, Inc. 156 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Multi Disciplinary > Patient Progress Notes Figure 17.55 Patient Progress Notes Data included on the Patient Progress Notes is outlined below: · Demographics Box (located upper right-hand corner) § Patient's Name § Admitting physician § Age, sex, & room number § Medical Record number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. · Entries § Each entry will fall under the appropriate application heading. § The heading will be highlighted with bold text and preceded by the following: o Time the entry was charted o The name and title of the individual who entered the information o Two to three character code indicating the application in which the entry was charted Application codes and descriptions: (P/A)-Physical Assessment (NSS)-Shift Summary (PCA)-PCA Medications (MED)-Pharmacy (EDU)-Education (VS)-Vital Signs (MO)-Medical Order (BSU)-Diabetic Record (ORD)-Ancillary Orders (F/S)-Floor Stock (NAC)-Nursing Activities (PL)-Problem List · Signature Line: An optional signature line is provided at the bottom of this report for the nurse primarily responsible for the patient's care. · The following is a header display of the Patient Progress Notes. © 2013 Computer Programs and Systems, Inc. Attachments 157 Patient Progress Notes Figure 17.56 Patient Progress Notes Attachments · The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that have been assigned to this section. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon >Multi Disc > Attachments Figure 17.57 Multi Discplinary - Attachments · Data located in Attachments · Deleted Items will display © 2013 Computer Programs and Systems, Inc. 158 ChartLink 5 Figure 17.58 Vital Signs - Attachments · Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms User Guide. will display if data is not present in this area to be viewed. · 17.9 Nurses Notes This section of the ChartLink 5 User Guide will discuss Nurses Notes. © 2013 Computer Programs and Systems, Inc. Attachments 159 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Nurses Notes Figure 17.59 Nurses Notes Initial Interview The Initial Interview is a document that includes information regarding the patient’s demographics, pertinent history, and discharge planning. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon >Nurses Notes > Initial Interview Figure 17.60 Initial Interview © 2013 Computer Programs and Systems, Inc. 160 ChartLink 5 Data included on the Initial Interview is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § The admitting physician § Age, sex, & room number § Medical Record number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. Patient Information Box Patient's name Name (person to contact in an emergency) Birth date and age Relation (of above person) Sex Address Marital status Phone Occupation Attending physician Religion Consulting physician Admitting diagnosis · The following is a full display of the Initial Interview report. © 2013 Computer Programs and Systems, Inc. Attachments 161 Initial Interview © 2013 Computer Programs and Systems, Inc. 162 ChartLink 5 Initial Physical Assessment The Initial Physical Assessment is a document that includes information regarding the patient’s initial vital signs and assessment of body systems. © 2013 Computer Programs and Systems, Inc. Attachments 163 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon >Nurses Notes > Initial Physical Assessment Figure 17.61 Initial Physical Assessment Data included on the Initial Physical Assessment Report is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § Admitting physician § Age, sex, & room number § Medical Record number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. · Initial Vital Signs § Temperature (including site) § Pulse (including site) § Respiration § Blood Pressure (including posture and extremity) § Weight § The date, time, name and title of the person who charted the information. Assessment Categories Each assessment will be preceded by the appropriate heading below: § Metabolic/Integument § Pulmonary § Cardiovascular § Gastrointestinal § Genitourinary § Reproductive § Musculoskeletal § Neurological § Injury Risk © 2013 Computer Programs and Systems, Inc. 164 § Pain ChartLink 5 § Psychosocial § Intravenous § Wound · The following is a full display of the Initial Physical Assessment report. © 2013 Computer Programs and Systems, Inc. Attachments 165 Initial Physical Assessment © 2013 Computer Programs and Systems, Inc. 166 ChartLink 5 Patient Progress Notes The Patient Progress Notes is a document that includes information from most POC applications charted during a given time frame. The Initial Interview and Initial Physical Assessment are not included in the Patient Progress Notes. Documentation from the multi-disciplinary applications prints to the report, also. It is printed at the end of shift and may be signed by the nurse assigned to the patient. · Select the desired date revealed in the lower split screen to display the appropriate Patient Progress Note. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon >Nurses Notes > Patient Progress Notes Figure 17.62 Patient Progress Notes Data included on the Patient Progress Notes is outlined below: · Demographics Box (located upper right-hand corner) § Patient's Name § Admitting physician § Age, sex, & room number § Medical Record number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. · Entries § Each entry will fall under the appropriate application heading. § The heading will be highlighted with bold text and preceded by the following: © 2013 Computer Programs and Systems, Inc. Attachments 167 o Time the entry was charted o The name and title of the individual who entered the information o Two to three character code indicating the application in which the entry was charted Application codes and descriptions: (P/A)-Physical Assessment (NSS)-Shift Summary (PCA)-PCA Medications (MED)-Pharmacy (EDU)-Education (VS)-Vital Signs (MO)-Medical Order (BSU)-Diabetic Record (ORD)-Ancillary Orders (F/S)-Floor Stock (NAC)-Nursing Activities (PL)-Problem List · Signature Line: An optional signature line is provided at the bottom of this report for the nurse primarily responsible for the patient's care. · The following is a full display of the Patient Progress Notes. © 2013 Computer Programs and Systems, Inc. 168 ChartLink 5 Patient Progress Notes © 2013 Computer Programs and Systems, Inc. Attachments 169 · Included: The Physician Entered Orders Report will automatically be included at the end of Patient Progress Notes. The report will include all verified medication, ancillary and nursing orders placed for the patient via physician order entry. This report will also include Verbal and Telephone Orders that are entered via Point of Care Order Entry. Data included in the Physicians Entered Order Report is outlined below: © 2013 Computer Programs and Systems, Inc. 170 ChartLink 5 · Patient Information § Patient's name § Account number § Medical record number § Date of Birth § Age § Sex § Room number § Any drug allergies documented through the CPSI System · Medication Information § Date/Time of order placement § Medication description, dosage, frequency, route, duration, priority and instructions § Flow rate and components for IV medications § Physician's electronic signature with credentials · Ancillary Order Information § Date/Time of order placement § Ancillary order description, quantity, frequency, duration, days and priority § Physician's electronic signature with credentials · Nursing Order Information § Date/Time of order placement § Description of Nursing Order § An Action if taken (Discontinue) § Physician's electronic signature with credentials · The following is a full display of the Physician Entered Orders Report © 2013 Computer Programs and Systems, Inc. Attachments 171 Physician Entered Orders Report © 2013 Computer Programs and Systems, Inc. 172 ChartLink 5 24 Hour Summary The 24-Hour Summary is a document that includes specific patient information charted within the previous 24 hours from the minute it is printed on the system. This worksheet provides both nurses and physicians details of the patient’s condition and plan of care. It is one of the primary tools used by nursing to conduct an organized and timely shift change. It is one of the reports preferred by physicians to use as reference while making rounds. © 2013 Computer Programs and Systems, Inc. Attachments 173 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon >Nurses Notes > 24 Hour Summary Figure 17.63 24 Hour Summary Data included on the 24 Hour Summary Format A is outlined below: · Demographics Box (upper right-hand corner) § Patient's name § Account number § Admitting and/or consulting physician § Age, sex, & room number § Medical Record number § Drug allergies documented through the CPSI System · Vital Signs § Pulse and Blood Pressure, displayed either graphically or numerically in one hour intervals § Temperature and respirations displayed numerically in one hour intervals · Hemodynamics (Optional) § CVP, PAP, PAWP and CO/CI values displayed in three hour intervals § In order for this information to be included, it must be set up by Nursing Administration. · O2/Ventilation Information § The user determines which seven of twelve options will be included. § Values display in three hour intervals NOTE: An asterisk (*) adjacent to any value on this report indicates multiple values have been charted within the specified time frame. The last recorded value is printed. Preceding values are available on-line or in Patient Progress Notes. · Intake © 2013 Computer Programs and Systems, Inc. 174 ChartLink 5 § The user determines which seven of twelve options will be included. § Values display in three hour intervals § The "OTHER" box combines all intake values not specified on the report. These details are available on-line or in the Patient Progress Notes § For Pediatric/Nursery chart types, an option to record breast feeding will appear. · Output § The user determines which 4 out of 18 options will be included. § Values display in three hour intervals § The "OTHER" box combines all output values not specified on the report. These details are available on-line or in the Patient Progress Notes. § Entries charted by frequency print in the top left corner of each box · Weight § Admission weight is printed in both pounds and kilograms. § Yesterday's weight in pounds and kilograms, with date and time charted is printed. § Today's weight in pounds and kilograms, with date and time charted is printed. · Diet § Date and time the information was charted § The diet, along with the date and time it was scheduled to begin. § Any comments entered § Percent consumed · Current Medications (Optional) § Includes all active medications at the time the report is printed § Medication description, dose, frequency, and autostop date if applicable § Does not include discontinued medications § In order for this information to be included, it must be set up by Nursing Administration. · Administered Medications (Optional) § Lists all medications administered during the previous 24 hours. § Date and time of last administration § Medication description § Location of administration, and the reason for PRN administration § Dosage § In order for this information to be reflected, it must be set up by Nursing Administration. · Omitted Medications (Optional) § Lists all medications omitted in the previous 24 hours. § Medication description § Omission date and time or check time § Reason for omission § Includes discontinued medications § In order for this information to be included, it must be set up by Nursing Administration. · Neuro Checks (Optional) § Neuro checks charted through the VS application during the previous 24 hour period § Date and time information was entered § Name and title of person who charted the entry · X1 {one-time} and PRN Medications (Optional) © 2013 Computer Programs and Systems, Inc. Attachments § § § § § 175 Lists all X1 & PRN administrations in the previous 24 hour period Medication description, quantity, frequency and time of administration Includes a reason for PRN medications Does not include discontinued medications In order for this information to be reflected, it must be set up by Nursing Administration. · Blood Glucose Readings (Optional) § Includes all administrations in the previous 24 hour period § Date and time entry was charted § Blood sugar level § Description of medication given (sliding scale insulin only) § Unit(s) of medication given and frequency · Blood Glucose Readings (Continued) § Any other interventions charted § In order for this information to be reflected, it must be set up by Nursing Administration. · The following is a full display of the 24 Hour Summary report (Format A & B). NOTE: The 24 Hour Summary report (Format B) has some different options than Format A. Format B also displays and prints in a horizontal format. Please refer to the hospital’s Information System department for more information on the two different formats. © 2013 Computer Programs and Systems, Inc. 176 ChartLink 5 24 Hour Summary (Format A & B) . © 2013 Computer Programs and Systems, Inc. Attachments 177 \ Figure 17.64 24 Hour Summary Format A © 2013 Computer Programs and Systems, Inc. 178 ChartLink 5 Figure 17.65 24 Hour Summary Format B © 2013 Computer Programs and Systems, Inc. Attachments 179 Shift Summary The Shift Summary Report is a document that includes all shift information charted the previous 24 hours via Point of Care. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon >Nurses Notes > Shift Summary Figure 17.66 Shift Summary Data included on the Initial Physical Assessment Report is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § Sex § Condition Code § Diet § Admitting Physician § Second Physician § Diagnosis § Working Diagnosis 1 § Working Diagnosis 2 § Length of stay § Patient account number § Age, sex, & room number § Medical Record number § Any drug/food allergies documented through the CPSI System § Advanced Directive § Smoking Status © 2013 Computer Programs and Systems, Inc. 180 § § § § § ChartLink 5 Isolation Status Fall Risk Language Ethnicity Immunization Entries: All shift summary information charted the previous 24 hours through Point of Care. · The following is a full display of the Shift Summary report. © 2013 Computer Programs and Systems, Inc. Attachments 181 Shift Summary Attachments · The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that have been assigned to this section. © 2013 Computer Programs and Systems, Inc. 182 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon >Nurses Notes > Attachments Figure 17.67 Nurses Notes - Attachments · Data located in Attachments · Deleted Items will display Figure 17.68 Nurses Notes - Attachments © 2013 Computer Programs and Systems, Inc. Attachments 183 · Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms User Guide. · will display if data is not present in this area to be viewed. 17.10 Education This section of the ChartLink 5 User Guide will discuss the Education reports. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Education Figure 17.69 Education Education Report The Education report is a document that includes multi-disciplinary information on how and when the patient was educated regarding diagnosis, medication administration, etc. © 2013 Computer Programs and Systems, Inc. 184 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Education Figure 17.70 Education Report Data included on the Education Report is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § Admitting physician § Age, sex, and room number § Medical Record number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. · Education Categories § Each category will be highlighted with bold text within a shaded gray box. § There are 34 categories that are all user-defined and can be set up for multi-discipline use. § Within the category up to thirty hospital-defined questions with up to twelve answers for each can be set up. § The questions appear in bold text with the responses listed below. § Under each category entries made will display in chronological order preceded by the date, the time entry made, and name and title of individual that entered the information. § Education questions can be integrated with the Physical Assessment and Initial Interview portions of the chart and will display on the Education report. Entries: Each entry will fall under the appropriate category. · The Education Report and the other reports listed in this section will display in Adobe Acrobat Reader format. © 2013 Computer Programs and Systems, Inc. Attachments 185 · The following is a full display of the Education Report. © 2013 Computer Programs and Systems, Inc. 186 ChartLink 5 Education Report Attachments · The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that have been assigned to this section. © 2013 Computer Programs and Systems, Inc. Attachments 187 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon >Education > Attachments Figure 17.71 Education- Attachments · Data located in Attachments · Deleted Items will display Figure 17.72 Education - Attachments © 2013 Computer Programs and Systems, Inc. 188 ChartLink 5 · Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms User Guide. · will display if data is not present in this area to be viewed. 17.11 Cardiopulmonary This section of the ChartLink 5 User Guide will discuss the Education reports. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Cardiopulmonary Figure 17.73 Cardiopulmonary Initial Interview The Initial Interview is a document that includes information regarding the patient’s demographics and pertinent history. © 2013 Computer Programs and Systems, Inc. Attachments 189 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Cardiopulmonary > Initial Interview Figure 17.74 Cardiopulmonary - Initial Interview Data included on the Initial Interview is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § The admitting physician § Age, sex, & room number § Medical Record number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. Patient Information Box Patient's name Name (person to contact in an emergency) Birth date and age Relation (of above person) Sex Address Marital status Phone Occupation Attending physician Religion Consulting physician Admitting diagnosis · The Initial Interview report and the other reports listed in this section will display in Adobe Acrobat Reader format. · The following is a full display of the Initial Interview report © 2013 Computer Programs and Systems, Inc. 190 ChartLink 5 Initial Interview © 2013 Computer Programs and Systems, Inc. Attachments 191 © 2013 Computer Programs and Systems, Inc. 192 ChartLink 5 Initial Physical Assessment The Initial Physical Assessment is a document that includes information regarding the patient’s initial vital signs and assessment of body systems. © 2013 Computer Programs and Systems, Inc. Attachments 193 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Cardiopulmonary > Initial Physical Assessment Figure 17.75 Cardiopulmonary - Initial Physical Assessment Data included on the Initial Physical Assessment Report is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § Admitting physician § Age, sex, & room number § Medical Record number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. · Initial Vital Signs § Temperature (including site) § Pulse (including site) § Respiration § Blood Pressure (including posture and extremity) § Weight § The date, time, name and title of the person who charted the information. · The following is a full display of the Initial Physical Assessment report. © 2013 Computer Programs and Systems, Inc. 194 ChartLink 5 Initial Physical Assessment O2 Saturation Graph The O2 Sat Bar Graph is a document that displays the O2LM, FiO2, and O2SAT, which is graphed and includes the method. © 2013 Computer Programs and Systems, Inc. Attachments 195 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Cardiopulmonary > 02 Saturation Graph Figure 17.76 Cardiopulmonary - 02Saturaton Graph Data included in the O2 Sat Bar Graph is outlined below: · Demographics box (located upper right-hand corner) § Patient’s name § Account number § Admitting physician § Age, sex, and room number § Medical Record number § Any drug allergies documented through the CPSI System · O2 Information § O2 L/M, FiO2, and O2 Sat values display numerically § O2 Sat values display as a bar graph § O2 Sat values display on the bar graph along with the method · The following is a full display of the O2 Saturation Bar Graph report. © 2013 Computer Programs and Systems, Inc. 196 ChartLink 5 O2 Saturation Bar Graph Comparative The comparative vertical report is an update of all test results for a patient account. © 2013 Computer Programs and Systems, Inc. Attachments 197 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Cardiopulmonary > Comparitive Report Figure 17.77 Cardiopulmonary - Comparative The report is a comparative summary presentation of all data with test names along the vertical axis and results listed chronologically along a horizontal axis. Collection dates and times are printed on the horizontal axis. Up to seven events will print per row with subsequent results wrapping below the most current results. Since this report is a complete record of all patient results, each report should replace the report previously charted. Preliminary reports with results that do not appear on the comparative report should remain on the chart until they print on the comparative. · The following is a full display of the Comparative report. © 2013 Computer Programs and Systems, Inc. 198 ChartLink 5 Comparative © 2013 Computer Programs and Systems, Inc. Attachments 199 Comparative-All Stays The Comparative All Stays report is a cumulative report of all test results for a patient . Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Cardiopulmonary > Comparitive - All Stays Report Figure 17.78Cardiopulmonary Comparative All Stays The report is a comparative summary presentation of all data with test names along the vertical axis and results listed chronologically along a horizontal axis. Collection dates and times are printed on the horizontal axis. Up to seven events will print per row with subsequent results wrapping below the most current results. Since this report is a complete record of all patient results, each report should replace the report previously charted. Preliminary reports with results that do not appear on the comparative report should remain on the chart until they print on the comparative. · The following is a full display of the Comparative report. © 2013 Computer Programs and Systems, Inc. 200 ChartLink 5 Comparative Comparative-Multifacility The Comparative All Stays Multifacility report is a cumulative report of all test results for a patient across all site associated facilities. © 2013 Computer Programs and Systems, Inc. Attachments 201 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Cardiopulmonary > Comparitive - Multifacility Figure 17.79 Cardiopulmonary Comparative Multifacility The report is a comparative summary presentation of all data with test names along the vertical axis and results listed chronologically along a horizontal axis. Collection dates and times are printed on the horizontal axis. Up to seven events will print per row with subsequent results wrapping below the most current results. Since this report is a complete record of all patient results, each report should replace the report previously charted. Preliminary reports with results that do not appear on the comparative report should remain on the chart until they print on the comparative. · The following is a full display of the Comparative _ Multifacility report. © 2013 Computer Programs and Systems, Inc. 202 ChartLink 5 Comparative _ Multifacility Detail Results The Detail report can be used as an alternative comparative report; however it only provides a results chart copy for inpatients. © 2013 Computer Programs and Systems, Inc. Attachments 203 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Cardiopulmonary > Comparitive - Multifacility Figure 17.80 Cardiopulmonary Detail Results This report is added to the previously printed comparative Detail reports on the patient's chart. Inpatients whose results are completed after being discharged in the system do not print on this report; they print on the M/R File report. · The following is a full display of the Detailed Report. © 2013 Computer Programs and Systems, Inc. 204 ChartLink 5 Detailed Report © 2013 Computer Programs and Systems, Inc. Attachments 205 Attachments · The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that have been assigned to this section. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon >Cardiopulmonary > Attachments Figure 17.81 Cardiopulmonary- Attachments · Data located in Attachments · Deleted Items will display © 2013 Computer Programs and Systems, Inc. 206 ChartLink 5 Figure 17.82 Cardiopulmonary - Attachments · Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms User Guide. · will display if data is not present in this area to be viewed. 17.12 Rehabilitation This section of the ChartLink 5 User Guide will discuss the reports located in Rehabilitation. © 2013 Computer Programs and Systems, Inc. Attachments 207 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Rehabilitation Figure 17.83 Rehabilitation Initial Interview The Initial Interview is a document that includes information regarding the patient’s demographics, pertinent history, and discharge planning. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Rehabilitation > Initial Interview Figure 17.84 Rehabilitation Initial Intrview © 2013 Computer Programs and Systems, Inc. 208 ChartLink 5 Data included on the Initial Interview is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § The admitting physician § Age, sex, & room number § Medical Record number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. Patient Information Box Patient's name Name (person to contact in an emergency) Birth date and age Relation (of above person) Sex Address Marital status Phone Occupation Attending physician Religion Consulting physician Admitting diagnosis · The Initial Interview report and the other reports listed in this section will display in Adobe Acrobat Reader format. · The following is a full display of the Initial Interview report. © 2013 Computer Programs and Systems, Inc. Attachments 209 Initial Interview © 2013 Computer Programs and Systems, Inc. 210 ChartLink 5 © 2013 Computer Programs and Systems, Inc. Attachments 211 © 2013 Computer Programs and Systems, Inc. 212 ChartLink 5 Initial Physical Assessment The Initial Physical Assessment is a document that includes information regarding the patient’s initial vital signs and assessment of body systems. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Rehabilitation > Initial Physical Assessment Figure 17.85 Rehabilitation Initial Physical Assessment Data included on the Initial Physical Assessment Report is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § Admitting physician § Age, sex, & room number § Medical Record number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. · Initial Vital Signs § Temperature (including site) § Pulse (including site) § Respiration § Blood Pressure (including posture and extremity) § Weight § The date, time, name and title of the person who charted the information. · The following is a full display of the Initial Physical Assessment report. © 2013 Computer Programs and Systems, Inc. Attachments 213 Initial Physical Assessment Attachments · The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that have been assigned to this section. © 2013 Computer Programs and Systems, Inc. 214 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Rehabilitation > Attachments Figure 17. 86 Rehabilitation - Attachments · Data located in Attachments · Deleted Items will display Figure 17.87 Rehabilitation - Attachments © 2013 Computer Programs and Systems, Inc. Attachments 215 · Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms User Guide. · will display if data is not present in this area to be viewed. 17.13 Dietary This section will discuss access to Dietary functions from ChartLink 5. NOTE: Specific diet items (example: Low Salt Diet, Clear Liquid Diet) can be ordered if the hospital is using specific items in the Dietary item master (versus the use of generic dietary items). The item description will update the diet field in Clinical Information, Medact, Diet reports, and POC reports. Also, entering a new diet order replaces the previous diet order in Clinical Information and the Medact. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Dietary Figure 17.88 Dietary Initial Interview The Initial Interview is a document that includes information regarding the patient’s demographics, pertinent history, and discharge planning. © 2013 Computer Programs and Systems, Inc. 216 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Dietary > Initial Interview Figure 17.89 Dietary Initial Interview Data included on the Initial Interview is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § The admitting physician § Age, sex, & room number § Medical Record number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. Patient Information Box Patient's name Name (person to contact in an emergency) Birth date and age Relation (of above person) Sex Address Marital status Phone Occupation Attending physician Religion Consulting physician Admitting diagnosis · The Initial Interview report and the other reports listed in this section will display in Adobe Acrobat Reader format. · The following is a full display of the Initial Interview report. © 2013 Computer Programs and Systems, Inc. Attachments 217 Initial Interview © 2013 Computer Programs and Systems, Inc. 218 ChartLink 5 Initial Physical Assessment The Initial Physical Assessment is a document that includes information regarding the patient’s initial vital signs and assessment of body systems. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Dietary > Initial Physical Assessment Figure 17.90 Dietary Initial Physical Assessment Data included on the Initial Physical Assessment Report is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § Admitting physician § Age, sex, & room number § Medical Record number § Any drug allergies documented through the CPSI system § In addition to the above mentioned box, a single line containing the patient's name, account number, age, sex, room number and page number will appear along the bottom edge of the page. · Initial Vital Signs § Temperature (including site) § Pulse (including site) § Respiration § Blood Pressure (including posture and extremity) § Weight § The date, time, name and title of the person who charted the information. · The following is a full display of the Initial Physical Assessment report. © 2013 Computer Programs and Systems, Inc. Attachments 219 Initial Physical Assessment Nutritional Calculations Items such as Nutritional Assessments that include the patient’s Basal Energy Expenditure (BEE) and Ideal Body Weight (IBW) can be calculated through result entry. © 2013 Computer Programs and Systems, Inc. 220 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Dietary > Nutritional Calculations Figure 17.91 Dietary Nutritional Calculations · The following is a full display of the Nutritional Calculations report. © 2013 Computer Programs and Systems, Inc. Attachments 221 Nutritional Calculations Attachments · The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that have been assigned to this section. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Rehabilitation > Attachments Figure 17.92 Dietary - Attachments · Data located in Attachments © 2013 Computer Programs and Systems, Inc. 222 ChartLink 5 · Deleted Items will display Figure 17.93 Dietary - Attachments · Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms User Guide. · will display if data is not present in this area to be viewed. 17.14 Diabetic This section will discuss access to Diabetic functions from ChartLink 5. © 2013 Computer Programs and Systems, Inc. Attachments 223 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Diabetic Record Figure 17.94 Diabetic Record Cumulative Report The Cumulative Report will display the report from the beginning of the patients stay to the current date. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Diabetic > Cumulative Report Figure 17.95 Diabetic Cumulative © 2013 Computer Programs and Systems, Inc. 224 ChartLink 5 Data included on the Cumulative Report is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name, Account Number and Medical Record Number § Admitting physician § Age, sex and room number § Any drug allergies documented through the CPSI System · Diet: The patient's current diet will display in the top right-hand corner of the report, just below the demographics box. · Documentation Area § Date and time of each entry charted § Name and title of the person who charted each entry § Blood sugar level and dose (if administered) § Type of Insulin or Hypoglycemic agent administered § The site where the medication was given § Any additional interventions that were performed · Sliding Scale: The scale is highlighted in a gray box. It provides the following information: § Date and time the scale was entered, as well as the name and title of the person who entered it § Low and high blood sugar values, as well as the appropriate insulin dosage § Comments, if selected to print. This is an optional feature, please notify the facility Information Technology Department. § If no sliding scale has been ordered or if one has been discontinued, it will be indicated by the following values and dosage: 0 - 999 0.00 © 2013 Computer Programs and Systems, Inc. Attachments 225 Diabetic Flow Sheet Daily Diabetic Report The Daily Report will display 24 hours of data and is used to reveal frequently entered data such that may be seen in an Intensive Care Unit. · Select the date from the lower split screen to view desired report. © 2013 Computer Programs and Systems, Inc. 226 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Diabetic > Daily diabetic Report Figure 17.96 Daily Diabetic Report Data included on the Daily Flow Sheet is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § Admitting physician § Account number, age, sex and room number § Medical Records number § Any drug allergies documented through the CPSI System · Diet: The patient's current diet will display in the top right-hand corner of the report, just below the demographics box. · Graphic Display § 24-Hour graphic representation of all insulin and blood sugar levels. § All blood sugar levels plot on the graph; however, only the most recent level/time in each 1-hour increment prints on the report. § Asterisks indicate more than one level charted within 1-hour increment. § Interventions print vertically under the time period for which they were performed. § Lab results plot separately and are indicated in bold. § Diet percent consumed also graphs. Information pulls from recordings performed in Medact. § Individual totals for NPH, Regular, IV and Miscellaneous insulin, as well as oral agents given, print in 1-hour increments. · Sliding Scale § Sliding scales print on a separate page. § The date, time, name and credentials of the person who entered the scale will print. § Indicates if the sliding scale is IV or subcutaneous. © 2013 Computer Programs and Systems, Inc. Attachments 227 § Gray indicates an inactive sliding scale. § White indicates an active sliding scale. § Comments: This is an optional feature. Please notify hospital Information Technology Department. · Legend: Located bottom left hand corner of the Diabetic Flow Sheet. * indicates more than one result during this time period ^ indicates a blood glucose > 1000 o or plain text indicates Point of Care entry · or Bold indicates Lab result NOTE: In order for lab results to pull to the Diabetic Flow Sheet, the POC control record must be set up to include the items from lab. The item descriptions listed in the POC control record must be set up in the Reference Range Tables. · The following is a full display of the ICU format of the Diabetic Flow Sheet. © 2013 Computer Programs and Systems, Inc. 228 ChartLink 5 Diabetic Flow Sheet Weekly Report The Weekly Report will display the most recent seven days of entered data for the patient. This report is utilized for capturing less frequently entered data such as seen on a Medical Surgical Unit. © 2013 Computer Programs and Systems, Inc. Attachments 229 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Diabetic > Weekly Diabetic Report Figure 17.97 Diabetic Weekly Report Data included on the Weekly Diabetic Flow Sheet is outlined below: · Demographics Box (located upper right-hand corner) § Patient's name § Admitting physician § Account number, age, sex and room number § Medical Records number § Any drug allergies documented through the CPSI System · Diet: The patient's current diet will display in the top right-hand corner of the report, just below the demographics box. · Graphic Display § 7-Day graphic representation of all insulin and blood sugar levels. § All blood sugar levels plot on the graph, however only the most recent level/time in each 6-hour increment prints on the report. § Asterisks indicate more than one level charted within a 6-hour increment. § Interventions print vertically under the time period for which they were performed. § Lab results plot separately and are indicated in bold. § Diet percent consumed also graphs. Information pulls from recordings performed in Medact. § Individual totals for NPH, Regular, IV and Miscellaneous insulin, as well as oral agents give print in 6 hour increments. · Sliding Scale § Sliding scales print on a separate page. § The date, time, name and credentials of the person who entered the scale will print. § It will indicate if the sliding scale is IV or subcutaneous. © 2013 Computer Programs and Systems, Inc. 230 ChartLink 5 § Gray indicates an inactive sliding scale. § White indicates an active sliding scale. § Comments, This is an optional feature, please notify hospital Information Technology Department. · Legend: Located bottom left hand corner of the Diabetic Flow Sheet. § "*" indicates more than one result during this time period § "^" indicates a blood glucose > 1000 § "o" or plain text indicates Point of Care entry · or Bold indicates Lab result NOTE: In order for lab results to pull to the Diabetic Flow Sheet, the POC control record must be set up to include the items from lab. The item descriptions listed in the POC control record must be set up in the Reference Range Tables. · The following is a full display of the Weekly format of the Diabetic Flow Sheet. Diabetic Flow Sheet © 2013 Computer Programs and Systems, Inc. Attachments 231 Attachments · The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that have been assigned to this section. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Diabetic > Attachments Figure 17.98 Diabetic - Attachments · Data located in Attachments · Deleted Items will display © 2013 Computer Programs and Systems, Inc. 232 ChartLink 5 Figure 17.99 Diabetic - Attachments · Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms User Guide. · will display if data is not present in this area to be viewed. 17.15 Miscellaneous This section will discuss access to Miscellaneous functions from ChartLink 5. © 2013 Computer Programs and Systems, Inc. Attachments 233 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Miscellaneous Figure 17.100 Miscellaneous Census Report The Physician Census is a document that provides a physician with a concise listing of the patients for whom he is attending or consulting, as well as the patient’s most recent vital signs. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Miscellaneous > Census Report Figure 17.101 Census Report © 2013 Computer Programs and Systems, Inc. 234 ChartLink 5 Data included on the Physician Census is outlined below: · Physician Name Box (located upper right-hand corner) § Physician's name § The name of the nursing unit § This information is duplicated along the bottom edge of the report as well. · Patient Information: A list of up to eight patients per page for whom the physician is either attending or consulting is reflected in separate boxes and includes the following information: § Patient room number § Patient name, age, sex, and length of stay § Admitting diagnosis § Most recent set of vital signs § Temperature (including site) § Pulse (including site) § Respiration § Blood pressure (including posture and extremity) § Most recent weight § Date and time the vitals were charted § Name and title of the person who charted the vitals NOTE: Patients, for whom a physician is consulting, are highlighted in a gray box. The attending physician's name is indicated at the top of the box. · The Census Report will display in Adobe Acrobat Reader format. · The following is a full display of the Census Report. © 2013 Computer Programs and Systems, Inc. Attachments 235 Census Report © 2013 Computer Programs and Systems, Inc. 236 ChartLink 5 Attachments The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that have been assigned to this section. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Census > Attachments Figure 17.102 Census - Attachments · Data located in Attachments · Deleted Items will display © 2013 Computer Programs and Systems, Inc. Attachments 237 Figure 17.103 Census - Attachments · Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms User Guide. · will display if data is not present in this area to be viewed. 17.16 Face Sheet This section will discuss the feature of the Face Sheet. © 2013 Computer Programs and Systems, Inc. 238 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Face Sheet Figure 17.104 Face Sheet Face Sheet The Face Sheet is the patient’s record of admission. Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon > Face Sheet Figure 17.105 Face Sheet © 2013 Computer Programs and Systems, Inc. Attachments 239 The data included on a Face Sheet is facility defined. Some examples of patient data that can be included on the Face Sheet is outlined below: · Patient Name · Room Number · Hospital Number · Address · Age · Birth date · Sex · Birthplace · City · State · Zip Code · Social Security Number · Religion · Patient Telephone · Spouse Information · Who to Notify in an Emergency · Patient Employer · Guarantor Name · Admitting Physician · Consulting Physician · Admitting Service · Admitting Diagnosis · Allergies © 2013 Computer Programs and Systems, Inc. 240 ChartLink 5 · Date of Last Admission · Admission Date · Time of Admission · Financial Class · Medical Records Number · The Face Sheet will display in Adobe Acrobat Reader format. · The following is a full display of the Face Sheet . © 2013 Computer Programs and Systems, Inc. Attachments 241 Attachments The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that have been assigned to this section. © 2013 Computer Programs and Systems, Inc. 242 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon >Face Sheet > Attachments Figure 17.106 Face Sheet - Attachments · Data located in Attachments · Deleted Items will display Figure 17.107 Face Sheet - Attachments © 2013 Computer Programs and Systems, Inc. Attachments 243 · Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms User Guide. · will display if data is not present in this area to be viewed. 17.17 Other This section will discuss the Other section under attachments located in ChartLink 5. Figure 17.108 Other Attachments The Attachments area will contain any Scanned Images, Electronic Forms or Photo Uploads that have been assigned to this section. © 2013 Computer Programs and Systems, Inc. 244 ChartLink 5 Select ChartLink 5 Whiteboard > select Patient Account > Attachments icon >Other > Attachments Figure 17.109 Other - Attachments · Data located in Attachments · Deleted Items will display Figure 17.110 Face Sheet - Attachments © 2013 Computer Programs and Systems, Inc. Attachments 245 · Setup to display items may be referenced in the Image Title User Guide or the Electronic Forms User Guide. · will display if data is not present in this area to be viewed. © 2013 Computer Programs and Systems, Inc. 246 ChartLink 5 © 2013 Computer Programs and Systems, Inc. CPOE 247 Chapter 18 CPOE 18.1 Overview The CPOE icon allows the user to access CPOE to review current or discontinued Pharmacy and Ancillary orders or existing Nursing orders. This is also where new Pharmacy, Ancillary or Nursing orders may be entered by the provider. This is discussed further in the ChartLink® CPOE User Guide. · This is a separately purchased application. Please see your CPSI Marketing Representative for further details · If a Patient Account is selected in the traditional ChartLink application, and access is gained to the Physician Problem List or the Physician Documentation applications, the ChartLink 5 application will open. The user may then select the CPOE icon located at the top of the ChartLink 5 Icon Bar. Select ChartLink 5 Whiteboard > Select Patient Account > CPOE Figure 18.1 © 2013 Computer Programs and Systems, Inc. 248 ChartLink 5 © 2013 Computer Programs and Systems, Inc. Physician Documentation 249 Chapter 19 Physician Documentation 19.1 Overview The Docs icon allows the user to access the Physicians Documentation application to review current and historical documentation for this patient account. This is discussed further in the Physician Documentation User Guide. This is a separately purchased application. Please contact your CPSI Marketing Rep for further details. · If a Patient Account is selected in the traditional ChartLink application and access is gained to either the Physician Problem List or Physician Documentation applications, the ChartLink 5 application will open. The user may then select on the Docs icon located at the top of the ChartLink 5 Icon Bar. The user may also access the ChartLink 5 application when accessing the Medication Reconciliation application through CPOE. Select ChartLink 5 Whiteboard > Select Patient Account > Physician Documentation Figure 19.1 © 2013 Computer Programs and Systems, Inc. 250 ChartLink 5 © 2013 Computer Programs and Systems, Inc. HIR 251 Chapter 20 HIR 20.1 Overview This ChartLink 5 feature is currently under development. Select ChartLink 5 sign on > HIR Figure 20.1 Chartlink 5 Icon Bar © 2013 Computer Programs and Systems, Inc. 252 ChartLink 5 © 2013 Computer Programs and Systems, Inc. Temporary Registration 253 Chapter 21 Temporary Registration 21.1 RegNew · The Register feature should only be used with CPOE. · Policy and procedures will need to be established to determine how and when Providers should use this option. Refer to the Temporary Registrations section in the Registration User Guide for further information on creating a temporary registration. 21.2 Whiteboard Function · The Register feature should only be used with CPOE. · Policy and procedures will need to be established to determine how and when Providers should use this option. · Temporary Registration from the ChartLink 5 Whiteboard should be used for Patient Accounts that have yet to be established in Person Profile. § The provider will receive the Temporary Registration screen o Signed on Provider will pre-fill in Doctor Section o Present date will pre-fill in Service Date Section. o Signed on User initials will pre-fill in Registered By Section. © 2013 Computer Programs and Systems, Inc. 254 ChartLink 5 Select ChartLink 5 Whiteboard > Reg New Figure 21.1 Whiteboard Temporary Registration · The new Patient Account will appear on the Physicians Whiteboard. Refer to the Temporary Registrations section in the Registration User Guide for further information on creating a temporary registration. 21.3 Patient Function Screen · The Register feature should only be used with CPOE. · Policy and procedures will need to be established to determine how and when Providers should use this option. · Temporary Registration from the ChartLink 5 Patient Function Screen should be used for Patient Accounts that have previously been established in Person Profile. Select ChartLink 5 > Reg New Figure 21.2 Chartlink Icon Bar · The provider will receive the Temporary Registration screen § All fields will pre-fill with data from Person Profile except the Patient Type © 2013 Computer Programs and Systems, Inc. Temporary Registration 255 Select ChartLink 5 Whiteboard > Reg New Figure 21.3 Temporary Registration Patient Function Screen · The new Patient Account will appear on the Physicians Whiteboard. Refer to the Temporary Registrations section in the Registration User Guide for further information on creating a temporary registration. © 2013 Computer Programs and Systems, Inc. 256 ChartLink 5 © 2013 Computer Programs and Systems, Inc. ChartLink Reference 257 Chapter 22 ChartLink Reference 22.1 Overview This section will discuss Reference information for ChartLink 5 and some of the tables that are associated with the application. 22.2 ChartLink Tables 1. From the Hospital Base Menu, select Master Selection. 2. From the Master Selection Screen, select Business Office Tables. 3. From the Business Office Tables screen, select Maintenance Menu. 4. From the Business Office Table Maintenance Menu, select CL Tables. Select Hospital Base Menu > Business Office Tables > Maintenance > CL Tables Figure 22.1 ChartLink Table Selection Enter Daily Password © 2013 Computer Programs and Systems, Inc. 258 ChartLink 5 Figure 22.2 ChartLink Tables ChartLink Groups ChartLink Groups may be created to give Providers access to patients from other Providers in that same group. Select Hospital Base Menu > Master Selection > Business Office Tables > Maintenance > CL Tables > ChartLink Groups Figure 22.3 ChartLink Group Maintenance · Code © 2013 Computer Programs and Systems, Inc. ChartLink Reference 259 § Default: Blank § Options: Up to a three-character alpha or numeric code. § Usage: Code will be entered in Physician Security to identify a physician as a member of a selected ChartLink group. · Description § Default: Blank § Options: Up to a 40-character alpha or numeric description. § Usage: Allows a brief description of the ChartLink Group. § Other options are as follows: o ?-Lookup - Displays a lookup of previously created ChartLink Groups. o “DEL”ete - Permanently removes the a created ChartLink Group. · Signature Overdue after ___ Days § Default: Blank § Options: Up to a three-character numeric code. § Usage: Code will be used to determine how many days after a transcribed document or an order has appeared in a physician's Electronic Signature queue before that signature is considered overdue. © 2013 Computer Programs and Systems, Inc. 260 ChartLink 5 ChartLink Control Table Page 1 NOTE: The ChartLink Control Table is utilized by several applications. Arrow markers indicate those controls related to the ChartLink 5 Application. Select Hospital Base Menu > Master Selection > Business Office Tables > Maintenance > CL Tables > ChartLink Control Table Figure 22.4 ChartLink Control Page 1 · Utilize confidentiality statement at sign on: § Default: Blank § Options: Y (yes), ? (check mark), or N (no) § Usage: Allows a confidentiality statement to display at sign on. Figure 22.5 Confidentiality Statement © 2013 Computer Programs and Systems, Inc. ChartLink Reference 261 ChartLink Control Table Page 2 NOTE: The ChartLink Control Table is utilized by several applications. Arrow markers indicate those controls related to the ChartLink 5 Application. Select Hospital Base Menu > Master Selection > Business Office Tables > Maintenance > CL Tables >ChartLink® Control Table> PgDn Figure 22.6 ChartLink Control Page 2 · Outpatient Tab Effective Date: · Default: Blank § Options: Bland or Number of Days § Usage: Controls how far back the system will look for accounts to populate the Providers Outpatient Listing on the ChartLink 5 Whiteboard. · CL Version: § Default: Blank § Options: N (Traditional ChartLink), 5 (ChartLink 5 § Usage: Determines ClientWare Version that will open upon Log In. © 2013 Computer Programs and Systems, Inc.

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