RCC OP Chemo IV Start/Stop Training Manual

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1 4/25/13 Page 1 of 6 RCC OP Chemo IV Start/Stop Training Manual Goal: IV Start/Stop time is required for billing purposes for Outpatient Chemotherapy and Infusion Therapy. The following steps outline how IV Start/Stop time will be documented electronically. Step 1: Log into Meditech TEST/Add patients to worklist Click on Meditech Enter information in the login screen. o Username: jd1234 o Password: (<ENTER> once) AT the HCIS prompt o HCIS: Click on F9 Key select TEST 5.65 <Enter> Go to PCS Status Board and add a patient with last name to your worklist Go to LOCATION from SB and view patients Step 2: ADD Standard of Care A Standard of Care (SOC) has been created for RCC OP Chemo. This SOC contains documentation formsyou will need. They are:admission Ht/Wt; Vital Signs; RCC OP Chemo Flowsheet. To add the SOC: From Intervention list Click on Add Intervention (Bottom menu)enter RCC Click to left of Standard of Care: Oncology/Chemo RCC Click Add and Close (Bottom menu) At the top Left select SOC-OPCHEMO Click on it to select Save Review New Documentation forms

2 4/25/13 Page 2 of 6 Step 3: Document Nursing Assessments Click on each assessment, select document from menu at the bottom of the page Document on each question Save To EditDocumentation: o Click on the intervention cell under the History column o Click on the black arrow on the row which contains the documentation you need to edit. o Make the edit and return twice, then save To UNDO Documentation o Click on the intervention cell under the History column o Click on the row/documentation you want to Undo (it will be green when selected) o Click Undo from menu at bottom of page o Enter Undo Reason, save o Click Return, then save Step 4: Document Medication Administration Click on emar review/ack medications Administer Med Pre Meds and File Administer Med Chemo Step 5: Document IV Start/Stop Time - Using Reassessment Option An assessment has been set up to display after administration of meds that require a Start/Stop time for billing purposes. The Pre-Med assessments have been set up to only require reassessment once. All Chemo medications may be documented more than once to capture necessary data that relate to the administration of the medication. This assessment is set up with a rule to allow it to display for only the outpatient infusion areas Chester River Infusion Clinic and RCC Outpatient Chemo Clinic. Reassessment notification to RN From the Status Board Within emar o See Reassess 1558 o o Click + in front of Reassessment below the protocol information Select Document Enter the appropriate information.

3 4/25/13 Page 3 of 6 Type of injection(im, SC, IV Push and Flush) will NOT require IV Stop Time. IF you want to enter a STOP time, for a flush for example, you certainly may. IV Infusion Status: Rules have been set up to help you remember what is needed for documentation for each of the following: Stopped time Restarted Time Still Infusing ALSO, you will be able to enter Titration Infusion Rate and Time of Rate Change Once you have entered the information File/SAVE PCS view of the assessment: The warning below will display if two reassessments are due at similar times. You can click Uncheck the med or click Cancel to ignore. If you want to document both, click OK.

4 4/25/13 Page 4 of 6 Step 6: Additional Information Documentation of KVO Fluid In addition to the IV Start/Stop time assessment, we have added an assessment to indicate what, if any, fluid is running as KVO. This will display at the time of administration. It was also suggested that for the few Chemo agents that should only have D5W or only have NSS running, the assessment provide only the appropriate fluid as a reminder. ***Fluids used for HYDRATION should be added to the emar as an order so that IV start and stop times can be captured electronically. Administer Med (Taxol) o Click on Taxol and select Administer *** SHS will SCAN patient/med in LIVE. o Select appropriate KVO Fluid o Save Stop 7: Documentation of Titration Select Rotuxan Administer Enter Dose

5 4/25/13 Page 5 of 6 Step 8: Electronic Medical Record View of Documentation The information entered here will go to the EMR and is able to be viewed in the Medication panel and Special Panels From Medication Panel Click in Last Dose field for the medication Documentation History will display Note: Adm Time; Reassessment Time and documentation Med Adm Time Med Adm Time Reassessment Time and Documentation Clicking in the conversation bubble will displaythe free text comment

6 4/25/13 Page 6 of 6 From MY Panels Click in the dose field or on the + sign to display information as shown abov When Vitals are recorded on the assessment: Data will flow to Medication panel, 24 hour panel, Special panel and Vitals Step 9: Reports A billing Report is available EMR Reports o My Panel o EMR Report Click the printer icon bottom right of screen Select Report Click the down arrow to select the report View/Print