Locate the compass Meditech 6.0 icon on the desktop. Double clicking on this icon will bring up a Citrix login window.

Transcription

1 EDM Physician Training Manual Logging on to Meditech 6.0: Locate the compass Meditech 6.0 icon on the desktop. Double clicking on this icon will bring up a Citrix login window. Log in with your user name. User name is your first and last name in lower case with a period between. Password contains first letter capitalized and number. When typing your password only dots are seen. When logged in you will see a Meditech login screen. Click on the Meditech-CS KOM icon to enter Meditech. Choose an HCIS to log into KOM.LIVE60F for the live environment or KOM.TEST60F for the test environment and click Signon. Click Signon at the bottom right hand corner of the Screen. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 1

2 EDM TRACKER Purpose: The EDM Tracker provides a starting point to all the screens and functions needed to view, edit and document patient information. The EDM Tracker displays pertinent information about your patient divided into various columns. This screen is interactive; you have the ability to change some information directly by double clicking on the specific column. Folder The Icon can click in this column to open chart of highlighted patient Completed Results Indicator field ED Room, Bed Triage/Priority Score Name/Chief Complaint(sam e/similar names appear in yellow Orders-type will be indicated. Time Status Event These buttons allow you to manage your patient list. Tracker Columns: Name/Chief Complaint: Same/Similar Names will appear highlighted in Yellow. Orders: The user can see if they have new orders. When orders have been complete they will turn from black to green to let the user know that they have a result. Results: When new results are completed the appropriate indicator will appear in this field. Directly review the result when clicking on the label. RN/ERP: Assign or change MD providing care for the highlighted patient. Along the right side of the tracker: This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 2

3 Lists: Can access different locations, find accounts, or your list. Tracker: Returns you to the EDM Tracker. On Call Staff: Use this screen to view a list of staff members currently on call. Clinical Data: Use this routine to enter, edit, or view information for a selected account. This is where you will document home medications and allergies. Manage Orders: Use this screen to view, enter, and edit acute care orders, medications, and order sets. Patient Reports: Use this function to print patient reports for one or more patients. (Patient snapshot, complete record (legal record)). Sign: Use this function to e-sign orders and documents that require Physician signature. Patient Snapshot: Use this screen to see the patient synopsis which includes the Triage, vital signs, height & weight, Allergies along with the Medications. Open/Close Chart: Opens and Closes the highlighted patient s chart Ready for Discharge: updates patient status Ready to Discharge. Management: Statistical graphs/logs related to care in the ED. Indirect: not utilized on April 1. Preferences: Use this screen to define your Status Board/EDM Tracker preferences. Selecting a Patient To select a patient click anywhere on the patient information line on the tracker. The default screen is the New Orders screen in the Enterprise Medical Record (EMR). When chart opens the header will display the patient name, age/date of birth, height/weight, allergies, account number/medical record number, location, location status, and resuscitation status(if known). Right side function buttons in open chart: Tracker: Takes you back to tracker Select Visits: Look at previous visits and select ones that you want to view. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 3

4 Summary through Notes: This is all information from the Enterprise Medical Record or EMR(In Magic, PCI). Any of these buttons that are red indicates new information since it was last reviewed by you. Summary: Shows Problems, Allergies, Active Medications and Home Medications. Review Vist: Provides in depth registration information. Notices: Notices currently only consist of critical labs. When this is highlighted red new notices are present. When viewed the notice is auto acknowldeged. New Results: Shows any new results on the patient. Abnormal results will be highlighted yellow for abnormal and red for critical. You are able to Graph any lab resulted. Vital Signs: Review vital signs entered by nursing. I & O: Review I&O s entered by nursing. Medications: Review medications ordered. Laboratory: Review lab results. Microbiology: Review micro results. Blood Bank: Review blood administration. Reports: Review any reports, Xray, CT, Pdoc, etc. Patient Care: Review nursing documentation. Notes: Review nursing notes. Orders: Access to Order Management for viewing all orders or placing orders in the ED. Amb Orders: Access to Ambulatory Order Management for writing prescriptions in the ED. Document: Access to writing a Progress Note, H&P and Discharge Summary. Sign: When highlighted in red indicates that there are orders and/or documents(reports) that require your electronic signature. Placing Orders: To place an order select patient by opening chart. Select: New Order, New Meds, or New Sets. *Bottom of screen function buttons(open chart): Under ORDERS tab. New Orders: Allows user to go into Favorites, Category Group, or Name. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 4

5 To select by category group click on + to open category that gives user a list of test that can be selected. Once correct order is found, first check box. Note blue edit box with asterisk. These orders require additional information. On Edit order screen, field required has asterisk associated. Fill in required information, and Ok at bottom right of screen is high lit. (Note: you are not able to place order until this step is completed if additional information is required.) You are brought to a screen to review your order(s), click okay. You reach a final screen, click Save to enter the users e-sign. New Meds: Allows user to go into Favorites, Category, and Name. By selecting New Meds it will give the user the option to search by favorite, category, or name. After picking the method of search for medication select the medication, route and time to be given stat select the Ok button at the bottom right of the page. This will then ask for user to review and then ask for the user to e-sign then it will allow user to file the new med order. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 5

6 New Sets: Allows user to pull up order sets in Kootenai Medical Center. User will have the option to lookup by personal favorites or Category. Restorable: Allows user to restore an order to active status. Convert: Allows user to convert an order into an Ambulatory order. Reconcile: Allows user to change discontinued order to active. Edit Multiple: Allows user to edit multiple orders at one time by clicking on the + sign to view orders that maybe edited. Graphing Lab Values You are able to Graph any lab resulted. For example: Clicking on Glucose will show only glucose results for the patient. To select data right click on the values. Selected data is indicated by a blank diamond. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 6

7 If graphing is desired click on the Graph button on the right. Note at the bottom of the screen the graphing range can be expanded to better see the data trend. Click Close in the lower right of the screen to exit the graphing routine. Electronic Signature When the button is red this indicates that there are orders that require your electronic signature. Click on the Sign button to access the esign queue. Orders to be signed list shows the date and time of the order, patient name, MR number, age and gender, reason for it needing esigned, test ordered, date and time, and ordering provider. Click on the Orders tab at the top of the screen to view your orders to sign. There are two options at the bottom of the screen: View & Sign or Reject. View & Sign Orders: View & Sign allows you to view the orders and Mark to Sign. All reports must be viewed before signing. Reject will allow you to reject an order(s) that are not yours. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By Page 7

8 Click View & Sign when orders are selected and a detailed view of the order is shown. Click Mark to Sign and the next order will be displayed. Note at the top of the screen is shown the number or orders and how many are marked for signature. When the end of the list is reached a page prompting for your Pin number is seen that includes a list of the order(s) that are being signed. Enter your Pin number and click Save to sign the list of order(s). Reject Orders: The Reject button allows you to reject an order and remove it from your sign queue that is not yours. Uncheck any order you do not want to reject. Click the Reject button. A screen with the order(s) that are being rejected, reason for rejection and a prompt for your Pin number. Default reject order is Not My Order. Click the down arrow for additional reason of Wrong Patient and Incorrect Entry. Choose the desired reason and enter your Pin number and click Save. The rejected orders are sent to HIM to assign to the correct provider. Ambulatory Orders or Prescriptions *Bottom of Screen function buttons(open chart): Under Amb ORDERS tab. On the ambulatory orders screen a heading of Home Medications will be seen. Click the to the left of the header to expand these for review. This is the same information that is available on the EMR Summary screen under Home Medications This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 8

9 This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By Page 9

10 Category of Pt History were entered as Home Meds upon admission. Rx indicates previous prescriptions that were written and are automatically added to the Home Medication List. If the prescriptions are no longer taken by the patient they will need to be removed during medication reconciliation so the patient s home medication list is accurate. Click on new medications to place new RX to take home. When saving conflict and allergy checking will be done. Conflicts are shown on the Resolve Ambulatory Conflict screen and must be resolved or the prescription cancelled. Click Save to continue filing the new prescription. The new prescription is added to the Home Medication list. The prescription will print with the discharge packet but can be printed manually by clicking Print at the bottom of the screen. When this option is used the new prescription is automatically selected for printing. Click Print at the bottom of the screen to complete the manual printing of the prescription. Override Screen and Options In this example there is a allergy to morphine and a record of other pain medications that have been prescribed including Lortab. Options are to Override, Erase or Replace the order. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 10

11 Override gives comment options. When selecting Override the MD Aware Administer as Ordered is selected. Erase asks for a comment selected from this same list and cancels the script. Replace functions in the same way and defaults back to the type ahead medication search. Meditech 6.0 ED Medication Reconciliation Home Medications: Nurse updates home medications in Triage Physician Reconcile: Pathway: Clinical>EDM Tracker>Open Chart>Orders>Reconcile This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 11

12 Reconcile: Will be highlit in red if new home medications need to be reconciled. The following screen will appear allowing the physician to hold all home meds or place a medication order utilizing continue button. Pt s own will not be utilized at this time. If continue is used the physician can edit the home med order utilizing the blue edit tab of the home med or green medication line. RED Starred Items will not go through interaction allergy checking. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 12

13 Can edit all orders by selecting items to be reconciled at the same time. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By Page 13

14 After changes are made then the user selects the Ok tab at the bottom right corner of the screen. This will bring the user to the current orders screen. Interaction/Allergy checking may bring up conflicts erase, override or replace as necessary. Current Orders Screen: this screen then allows one more look at the changes made before the change is completed. Select the Save tab in the bottom right corner. This will launch the unsaved data screen. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By Page 14

15 The Unsaved Data screen will prompt this is when the Provider will Enter Pin and click on the Save Selected tab at bottom of screen. This completes the medication reconciliation of home meds upon a patient entering the ED. Ambulatory Orders: Creating new prescriptions and reconciling for discharge. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 15

16 *Bottom of Screen function buttons(open chart): Under Amb ORDERS tab. On the ambulatory orders screen a heading of Home Medications will be seen. This will show all of the patients home medications and any prescriptions that have been written previously. Click the to the left of the header to expand these for review. This is the same information that is available on the EMR Summary screen under Home Medications Categories: Pt History were entered as Home Meds in Triage. Rx indicates previous prescriptions that were written and are automatically added to the Home Medication List. To complete the med recon process at discharge the status of every medication needs to be edited using the following choices: This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 16

17 o Resume: continue taking at home This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By Page 17

18 o Discontinue: Stop taking medication (this will remove med from the home med list.) o Renew: available if previous RX places an prescription. o Cancel: Cancel out medication. New Prescriptions: Click on new meds. May alter string of medication using edit or green fields within medication chosen. Stars with blue edits indicate further required fields need to be completed. Place all OTC meds as new ambulatory order. These will file to the home med list for the patient upon discharge. Click OK at the bottom right of the screen shows the new Rx as a new Ambulatory Order ready to be Saved. When saving conflict and allergy checking will be done. Conflicts are shown on the Resolve Ambulatory Conflict screen and must be resolved or the prescription cancelled. Click Save to continue. The new ambulatory home meds will file to the home med list and the prescription field within the discharge function. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 18

19 Printing prescriptions: To print the ambulatory meds as an RX for patient to fill separately check the medication and print. Do not check OTC meds unless wanting to print a prescription for patient to go home with. Home Meds: Discharge: After the physician completes the reconcile process in orders and ambulatory orders, the nurse reviews the home This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 19

20 med list for the correct medications as outlined in physician This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By Page 20

21 prescription/discharge instructions and updates accordingly. Then nurse updates the last dose/time taken. Then nurse prints the comprehensive home medication list after these updates via the discharge functionality it is also set to print with the discharge packet. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By Page 21

22 This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By Page 22

23 Adding Favorites To add this medication and string to favorites click Manage Favorites at the bottom of this screen. On the Manage Favorite Ambulatory Order List both previous and new prescriptions will be preselected to add to favorites. Click Save to save these to the favorites list. Example of what the two above prescriptions look like when added to favorites. Below is the tab that will allow in an open chart the user to manage favorites. Printing/Reviewing Patient Reports To print or view MD Summary report, highlight selected patient from tracker, enter chart and choose PT Snapshot button from right menu keys. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By Page 23

24 view of print report. At the bottom of the screen there is a report tab click on tab. To print or view patient report highlight and select Patient Report button on right side of screen. This will give the user the option to select patient/s to The screen above will come up in the patient report format box will have the Ed summary and Ed MD summary select. After making the selections select OK at the bottom right of the screen. Next will give selections to view, print, download, and mail. Select one and then select OK. This command will then let you view etc. ED Visit Data: Patient info for this visit. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 24

25 Activity tab at top shows Providers, Complaints, Interventions, or All. Patient snap shot: To print or view MD Summary report. Worklist: Will show the RN assessments attached to the patients current chart. Mar: Example- medications ordered and given during the visit at hospital. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By Page 25

26 Write Note: Discharge Instructions, Nursing Admission Note, Simple Nursing Note, ect. TAR: This is the place that the nurse will be recording the blood transfusions and blood product use. Discharge: The tab that will be used to place patient for ready for discharge status in the ED. This includes the diagnosis and information for patient to take home. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By Page 26

27 Discharging/Departing a Patient From EDM To start the discharge process, click the Discharge button of the open chart. The patient status cannot be in a READY TO DISCHARGE status unless REG ER admission status occurs. Can still enter information but cannot Discharge off the tracker. Discharge Plans Tab This will bring you to the screen, noted with the button at the top. To enter the discharge information, use the drop down arrows to the right and make a selection from the menu. Instructions: Not utilized at this time, will have to input free text what instructions given. Stand alone forms: Release from school, PE, etc. Prescriptions: For physician use only. Forms: all forms created as stand alone. Referrals: Looks to referral lookup. Additional Free text: opens to word document. Can use canned text (if created) or free text. Physicians should record instructions given here. Can click in item detail section to give patient further instructions (see green arrow) This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 27

28 Discharge Data Tab Provider: will default in. Status: will default in from current status on tracker, or when RDC button is clicked. Time Seen by Provider: Time stamp from the ERP in Room Status Event or can be manually entered. Triaged at: defaults in based on when triage occurred. Other ED Providers: can assign more then one ED provider. Clinical Impressions: Medical findings by the physician. Discharge Disposition: To be completed by physician. Condition: patient condition recorded by provider. Discharge comment: Free text box. Discharge date and time: Documenting in this field will take a patient off the tracker. It will be grayed out until REG status occurs. Discharge Interventions: Can associate required or recommended assessments. Can add from here using + at bottom. To document check of assessments and click document. Warning can occur based on facility decision which assessments are required upon discharge. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 28

29 Once discharge data and plan have been completed may print packet or each form separately. Printing Packet/Forms To print the patient s discharge packet, click the Print Packet button at the bottom of the screen. Can print by type instead (discharge reports). This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By helpdesk@kh.org Page 29

30 Information previously entered in the Discharge screen will now print. This material is the intellectual property of Kootenai Health. Do not download, share, or redistribute without prior permission. With questions about any projects or services, please contact the 24/7 Kootenai Health Information Technology Help Desk. By Phone: (toll free) or By Page 30