Download Slide 1

Before we Begin
• Practice Logging in to ensure your password works
appropriately
• Once you have logged in, select the status board
• Select Lists
• Select Find Patient by Inpatient Location
• Select ICU.MV
• Find patient: REHAB,TRAIN
• Launch the Open Chart
• Select to suspend your session
• Enter your PIN – To re launch the session
– If you need to reset your PIN – Please call the support
center 5999
Meditech 6.0 Upgrade
Rehab
Session I
Acronyms
• PCS: Patient Care System
– Intervention and Outcome Documentation
– Notes
• EMR: Electronic Medical Record
– Review clinical documentation
• OM: Order Management
– Enter Orders
Agenda
• PCS: Patient Care Systems
– Overview
– Status Board
– Worklist
– Care Planning
– Documentation Functions
• EMR: Electronic Medical Record
– Reviewing patient information
Rehab Main Menu
• List of Routines and Reports
• PCS Status Board will provide most nursing care
routines
Rehab Main Menu A
• Physician Care Manager
– View Patient Information - EMR
• PCS Status Board
– Patient Care Desktop (Contains several patient care applications)
– Inpatient or ED Worklist Documentation –
Assessments/Interventions/Outcomes
– View Patient Information - EMR
• EDM Tracker
– Patient Care Desktop (Contains several patient care applications)
– ED Patient Documentation - Assessments/Interventions
• Admissions - Reports
– Bed Roster
– Discharge Register
Rehab Main Menu
• Reconciliation Menu
– Therapists Desktop – Charge Entry
– Reconciliation Reports
– Billing Reports
• Imaging and Therapeutic Services
– Management Routines and Reports
• Print Operating List
– Report Routine: OR, PAT, Day Surgery Schedules
• Provider Look-Up
– Routine to Look Up Physician Contact Information
PCS: Patient Care Systems
Status Board
PCS Status Board
Patient
Assignment
List
Status Board
Function
Buttons
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Patient Assignment List/Home Page
Displays Pertinent Patient Information
– Relevant to the particular patient location
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Patient Care Routines &
Function Buttons
ie: Psych, MedSurg, Rehab, etc
Continuously Refreshes with new information (every 5 minutes)
Launching pad to various patient care routines
My List
• Manually Add Patients to your list
– Pts are Retained From One Log-on to the Next
• Discharged Patients Remain on your Status Board
until manually removed
– Enables Care Provider to Complete Documentation
even after the patient has left the facility
• Manually Remove Patient from your List
– Once you have Completed your Documentation and the
patient has been discharged (or you are leaving for the
day)
• The more patients on your List the longer the
status board will take to load
Adding Patients to your List
• [Lists] Button provides options to search for and add patients to your List
– Find Account
• Search for single patient by patient name
– Find Patient by Inpatient Location
• Provides a list of patients admitted to each location
• Provides the ability to add multiple patients to your list at one time
– My List
• Launches your patient assignment list
Video Demonstration II
PCS Status Board
PCS Status Board
Exercise A: Find Patient by Account
1. Click [Lists]
2. Click [Find Account]
3. Type Patient’s Name (Last Name, First Name)
– Use assinged REHAB,TRAIN patient
4. Click to the select the patient account
– Select the Account Number with the Admin In Registration
Type
– The status Board will Appear
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Click [Add to My List] – Footer Button
Click [Lists]
Select [My List]
Confirm this new patient has been added to your List
Exercise B: Find Patient by Location
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Click [Lists]
Click [Find Patient by Inpatient Location]
Select [Test ICU.MV Location]
Click [Assignments] - Right hand panel
Place a checkmark to the left of a couple of patient
names
Click [Add to My List] -Footer Button
Click [Lists] - Right hand panel
Select [My List]
Confirm that both patients have been added to your
assignment list
Open Chart
Open Chart
• All Inclusive Patient Care Routine
– Review Patient Data
– Complete Assessment Documentation
– Enter Orders
Open Chart
• EMR Electronic Medical Record
– Review Patient Data
• OM Order Management
EMR
– Review Orders
• PCS Patient Care System
– Worklist
• Intervention/Assessment Documentation
– Write Note
• Clinical Data
• View Allergies
• View Home Medications
• Enter/Review Patient information
OM
PCS
Open Chart: Patient Header
Location, Room, Bed
Age, Sex DOB
Allergies
Height/Weight/BSA
Admit Status
Medical Record
Number
Account Number
Worklist
Worklist
Worklist
Open
Chart
Routines
Worklist
Functions
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Open Chart defaults to the worklist tab
Documentation Routine
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Interventions, Assessments, & Outcomes
Worklist is shared by all Care Providers
Care Items display based upon Care Provider Type
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PT Assessments display for Physical Therapist
OT Assessment Display for Occupational Therapists
SLP Assessments Displays for Speech Language Pathologists
Worklist: Standard of Care
– Upon registration a Standard of Care Automatically defaults
• Vital Signs will display for Rehab automatically
– For the first encounter, you will add an intervention set before you begin
documenting
– To Add an Intervention or Intervention set, click the Add Button
Rehab Intervention Sets
• Group of Interventions/Assessments
• Added based upon services provided
• Each set will provide the basic interventions
needed for all patients
• Additional interventions/assessments can be
added as needed
Rehab Intervention Sets: Physical Therapy
• PT Inpatient Set
– PT Inpatient Evaluation
– PT Inpatient Visit Note
– GRP PT/OT Therapeutic Exercises
– GRP Balance Assessment
– GRP ROM Assessments
– GRP Gross Muscle Strength
• PT Inpatient Orthopedic Set
– PT Inpatient Evaluation
– PT Inpatient Visit Note
– GRP PT/OT Therapeutic Exercises
– GRP Balance Assessment
– GRP ROM Assessments
– GRP Gross Muscle Strength
– Same as above Plus CPM
Rehab Intervention Sets: Occupational Therapy
• OT Inpatient Set
– OT Inpatient Evaluation
– OT Inpatient Visit Note
– GRP PT/OT Therapeutic Exercises
– GRP Balance Assessments
– GRP ROM Assessments
Rehab Intervention Sets: SLP
• SLP Inpatient Set
– SLP Speech - Language Evaluation
– SLP Inpatient Visit Note
• SLP Inpatient Set
– SLP Bedside Swallow Evaluation
– SLP Inpatient Visit Note
Adding a New Intervention Set
• Intervention Sets or Individual Interventions may be added to the worklist
• Additional Interventions may be added as needed
• To add new intervention or set use the [Add] button
Add Intervention Set Routine
• The Quickest Method of searching for an Intervention is by [Any Word]
– Searches the entire intervention name
• Click [Any Word] and type the intervention name you wish to add
Add Intervention Set Routine
• Type the name of the intervention set and click enter
• Select the Intervention from the List and click save
Exercise: Adding a New Intervention Set
• From the Status Board Launch the patient’s open chart
by placing a checkmark to the left of the patient’s name
• From the Worklist, click [add]
• Select Intervention Sets
• Enter PT, OT, or SLP (Based on your provider type)
• Select one of the following
– PT Inpatient Set
– OT Inpatient Set
– SLP Inpatient Set
• Click Ok
• Confirm that the Interventions display as expected
Exercise: Adding a New Intervention
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Use the same patient
From the Worklist, click [add]
Select Interventions
Select one of the following
– Sensation Assessment
– Stair Climbing assessment
– SLP Voice Eval
• Select the assessment
• Click Save
• Confirm that the Interventions display as expected
Individual Interventions
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Tendon Reflex Assessment
Sensation Assessment
Ambulation Assessment
Gait Pattern Assessment
Postural Screen Assessment
Stair Climbing Assessment
Lymphedema Assessment
Extremity Circumference Assessment
Neural Tension Assessment
SLP Modified Barium Swallow
SLP Voice Eval
SLP Fluency Eval
SLP Bedside Swallow Eval
SLP Laryngectomy Eval
Worklist
• Interventions/Assessments will display on the worklist
to be documented
• The worklist is clickable and sortable
• Click any of the worklist headers to sort the list
Documentation Overview
Documentation Overview
• Documentation mode defaults to flowsheet
– Provides a view of prior documentation
– Mode Button will toggle to Questionnaire mode
• Similar to a paper assessment
Documentation - Flowsheet
White Column =
Documentation
Mode
Gray
Background =
View Mode
Recall is
Enabled for
PMH
Current Date/Time
Defaults
Documentation - Questionnaire
• Clicking Mode will toggle to Questionnaire Style
• You may toggle between Questionnaire and
Flowsheet mode at any time within documentation
Video Demonstration IV
Documentation
Documentation
Exercise D: Documenting Inpatient Eval
1. Start from the worklist
2. Place a checkmark in the now column for the Inpatient
Evaluation
3. Click [Document]
– Confirm the time column displays the current date/time in the
header
– Review the documentation
• Displaying from the last admission
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Click [Mode] to toggle to Questionnaire Mode
Document the first Patient Profile Section and click save
Click [Save]
Confirm the last done column updates with the last time
the intervention was documented
EMR Patient Care Panel
• Displays PCS Documentation
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Assessments
Interventions
Outcome
Care Plan
Exercise E: Reviewing Documentation - EMR
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Click [Patient Care Panel]
Confirm that the [Assessment] Tab Defaults
Select to view the Inpatient Evaluation Documentation
Place a Checkmark to the left of the Assessment Name
Click [View History]
Confirm that documentation displays
Click [Back]
Click [Plan of Care] Tab – Header
Click the [+] Symbol (in the description header) to
Expand the Components of the Care Plan
• Review the Care Plan Components
Break
1 Hour 30 Minutes
(15 Minute Break)
Documentation Frequencies
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Assessments and Interventions for the patient display on the worklist
Frequencies vary based upon protocol and physician orders
Frequency column indicates how often to document
Last done column indicates the last time the assessment was documented
Frequencies can be edited as needed based upon a particular Order or
Protocol
Documentation Functions
Documentation – Instance Type
– Enables multiple instances of documentation for various body
locations, positions or situations
• PT Treatment Goals
– Click the New PT Short Term Goal text
– Enter free text
Documentation – Instance Type
• Document the fields for the situation/instance
• Repeat the instance type documentation for the
new Short Term Goal
Documentation – Back Time
• To back date/time your documentation, click the drop down
arrow in the header
• Adjust the date/time to reflect when the data was collected
Documentation – Expand/Collapse
• Clicking the [-] symbol will collapse the field
within the section
Documentation – Collapse
• Notice the temperature section is now collapsed
• You may now click the [+] symbol to expand
• Some sections will default as collapsed – Notice the Thermal Management
Documentation defaults this way and can be expanded as needed
• Documentation that is infrequently utilized will default as collapsed and
must be manually expanded as needed
• The Manual Expand/Collapse will stick for the current assessment only
Exercise F Part A: Documentation Functions
- Back Documenting
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Select the [worklist] routine
Select Inpatient Visit Note
Click in the now column for the Inpatient Visit Note
Click [Document]
Back Document 1 Hour in the Past
– In the Header, click the drop down to the right of the
Date/Time Field
– Change the time to 1 hour in the past
• Document
• Save
Exercise H: Review Documentation in EMR
• Select [Patient Care Panel] in the EMR
• Place a checkmark to the left of the Inpatient Visit
Note
• Click View History
• Confirm that the Inpatient Visit Notes displays
under the adjusted time (1 hour in the past)
• Click [Back]
Recall Values
Recall Values
• Recall Values provides the ability to pull prior documentation to the current
assessment
• This function is enabled for a select number of assessments
• To invoke the recall values function, click the [Recall] Button
Recall Values
Recalls the entire
assessment
Recalls the section
Recalls the individual
query
• Assessment displays in green
• A column of diamonds appear to the right
• Select the diamonds to recall individual queries, entire sections, or the whole
assessment
• It is critical that you review the recalled information to ensure accuracy before
saving
• Recalling & saving = Signing your name to the documentation
Exercise I: Recall Values
• Use the first TEST Patient on your Blue Card
• Document Inpatient Visit Note
– Click in the now column to select the Inpatient Eval
intervention
– Click Document
– Click Recall
– Notice the screen turns green and diamonds appear in the
right hand column
– Click to recall one query: select to the right of the pertinent
medical history
– Click to recall the entire assessment: select to the right of
the Inpatient Eval
• Confirm the entire assessment has recalled
– Review all documentation to ensure accuracy
– Click Save
Care Plan
Rehab Problems/Goal/Plan
• Short Term Goals, Long Term Goals, and Treatment
Plans are established in the Inpatient Evaluation
Exercise: Documenting Patient Goals and
Rehab Treatment Plan
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Document the inpatient evaluation
Place a checkmark in the now column
Click Document
Click Mode to toggle to questionnaire mode
Scroll to the bottom of the assessment and find
the PT Treatment Goals
6. Indicate two short term goals
1. Click new short term goal to start an instance and free
text the first goal
1. Document the assessment
Exercise: Documenting Patient Goals and
Rehab Treatment Plan
1. Click new short term goal to start an second instance
and free text the second goal
1. Document the assessment
2. Create a new instance for a long term goal
3. Document the patients treatment plan
Review the Goals in the Rehab
Summary Panel
• Click Clinical Panels
• Select Rehab Summary Panel
• Confirm that the Rehab Long Term Goals,
Short Term Goals, and Recommendations
display
Open Practice Session
• Practice Documenting – Assessment Review
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PT Inpatient Set
– PT Inpatient Evaluation
– PT Inpatient Visit Note
– GRP PT/OT Therapeutic Exercises
– GRP Balance Assessment
– GRP ROM Assessments
– GRP Gross Muscle Strength
PT Inpatient Orthopedic Set
– PT Inpatient Evaluation
– PT Inpatient Visit Note
– GRP PT/OT Therapeutic Exercises
– GRP Balance Assessment
– GRP ROM Assessments
– GRP Gross Muscle Strength
– Same as above Plus CPM
• OT Inpatient Set
– OT Inpatient Evaluation
– OT Inpatient Visit Note
– GRP PT/OT Therapeutic Exercises
– GRP Balance Assessments
– GRP ROM Assessments
OM/EMR Training
Agenda
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Introduction to the EMR
Allergies, Code Status
Non-Med Order and Order Set Entry
Consults and Uncollected Specimens
Acknowledgment and Incomplete Orders
Post-Filing Edits to Orders
Entering Requisitions
Intro to EMR
• Electronic Medical Record
• Integrated system so same information is
viewable regardless of point of entry or
desktop
• Central access point for all results, patient
demographic information, reports, clinical
documentation, and clinical data.
Intro to EMR
•Selected tabs represent the EMR, viewable from all desktops with shared
information
•Patient header includes name, age, DOB, ht, wt, MRN, Acct number, Reg status,
location/room/bed, and allergies
•Items that have information “new to you” will be highlighted in red.
“i”: More Information
•Small “i” next to patient name provides additional information such as
allergies, height, weight, admit date and time, BMI, and Code Status.
Select Visits Panel
•This panel allows you to select the visits for which you wish to view
patient data. Choose a time period and visit type, or manually check
off the visits you wish to view. Current visit is the default.
Summary Panel
•The summary panel holds clinical, demographic, and legal information
regarding the patient. Allergies, home medications and problems
(diagnoses) can be edited via the blue edit button. Allergies and home
medications are usually edited on the Clinical Data screen which will be
covered later.
Summary Panel (cont)
•The legal indicators page of the summary panel includes important patient
information such as patient rights information, language, immunization,
readmission data, blood type, precautions, fall risk, and Braden score. This
information is also viewable for all visits by selecting the “all visits” tab.
Review Visit
•Review visit contains pertinent admission information including reason for
visit and physicians associated to this patient visit.
•The “More detail” footer button provides additional demographic and
administrative information.
•The patient abstract can be viewed and printed using the “Abstract” footer.
Notices
•The notices panel displays those notifications that have been sent to the
physician desktop for acknowledgement. These include critical lab results,
consultations, and certain nursing events such as patient falls.
•The Send Notice button will allow users to manually queue this notice to
another physicians desktop that may need to be aware of the result/event.
New Results
•The New Results panel shows new labs and reports that are new to you. They
can be sorted to include data from the last 24 or 48 hours. Tests with multiple
results will be listed in a separate date/time column.
•All critical results in Meditech are shown highlighted in red/pink and abnormal
results will always show in yellow. Clicking on the result will show additional
information including the reference range for the test.
Clinical Panels
•Clinical panels are constructed to provide a comprehensive view of the patient by pulling
various types of patient data onto one panel. Additional clinical panels can be found by
selecting the “Panels” footer button. Displayed is the M/S Handoff panel.
•Information is trended by date/time, but different time increments can be selected using the
footer buttons.
•You can also choose to pull in data from previous visits by selecting the Visits footer button.
Vital Signs
•Documented Vital Signs from the nursing assessment appear here. Additional
documentations will be trended in an adjacent column by date/time. For
patients with large amounts of documentation, the arrows at the top of the
screen allow for scrolling through older documentation.
I&O
Documented intake and output will be listed here. Again data will be trended
by date and time and can be adjusted to display increments of 1, 4, 8, 12, and
24 hours.
Medications
The default on the Medications tab, is the medication list which is a simple list of
all medications during this patient’s visit, but can be expanded to include
medications from all visits.
Clicking the header of each column allows the list to be sorted accordingly.
Additional filters can be applied using the footer buttons at the button.
Medications cont
The second tab on the Medications panel provides a view only display of the
MAR. All information on the MAR can be viewed, but no documentation can take
place here. You must visit the true MAR for this.
The detail footer button allows for viewing of additional medication information,
such as the flowsheet, monograph, medication detail, protocol/taper schedules,
and any associated data.
Laboratory
The Laboratory Panel displays all lab data separated out by category. This
defaults to the visits selected, but all visit data can be displayed by choosing that
tab. Clicking the name of the test will launch you to a list of all results for that test.
Clicking the result itself will launch you to a screen to view additional test data,
such as the reference range.
Laboratory cont
Lab reports can be printed by clicking on the date and time header of the lab
panel. The user will be launched to a collection data screen, where he/she can
select lab report and print the data.
Microbiology
The Microbiology panel displays all microbiology tests that have been received
into the lab. The status and results will be displayed with the procedure. Clicking
on the notepad will launch the user out to the final report.
Blood Bank
The Blood Bank Panel allows for Blood related information to be tracked on the
patients. The LAB/BBK department will update information in this panel along
with the Blood Product Infusion Record/Reaction documentation done in nursing.
Reports
The reports panel shows all reports that have been entered on the patient,
including radiology report, cardiology reports, dictated physician reports,
physician documentation reports, as well as Allscripts reports once they are live
in the system. *Initially Allscripts reports will be housed in the patient paper chart.
Clicking the notepad will launch you to the report for viewing and printing.
Patient Care
The Patient Care tab provides a view only overview of all assessments and
interventions documented on the patient. The plan of care is also viewable from here.
The information can be sorted out by date, name, recorded by, and provider type.
Patient Care cont
Clicking onto the name of an assessment or intervention will launch you into a
view only display of the documentation. No edits can be made from this panel.
Notes
The notes panel displays all notes entered on the patient by nursing,
physicians, and other staff. Dictations and Physician Documentation reports
(such as Progress Notes, H&P, Discharge Summary, etc) are not found here.
They are on the reports panel. To view, either check off the box next to the
desired note and click “View Selected” or clicking directly on the note.
Orders
Orders will be discussed in detail later in the training. For purposes of the EMR,
however, the orders panel is accessible to all users on any desktop. All active
orders will be displayed on the current orders table and the history panel
contains these as well as cancelled, completed, and discontinued orders.
EMR
• Electronic Medical Record (EMR)
Exercise M: EMR
• Use: MTPatient,TEST
• Where are two places in the EMR that I can
find documented allergies on a patient (Hint:
Clinical data is NOT part of the EMR)?
• Where can I view the last medication
administration in the EMR (Hint: your nursing
MAR is not part of the EMR)
• How can I easily tell whether a lab is of
abnormal or critical value?
• If I want to see a trend in a patients vital signs,
how would I accomplish this?
EMR Hands-On
• Use MTPatient,Test
• What is the easiest and most succinct way to
locate a patients standard of care and
individualized plan of care?
• It is the end of your shift and you are
preparing to hand off your patient, where
would be the best place to find a
comprehensive overview of that patient for
that shift?
• On the day of go live, where should you go to
find all scripts reports?