2017 RN Refresher Workflow Best Practices Captions

Transcription

1 Slide Caption Agenda 2 Did you know that we are able to peek at how staff are moving around within PowerChart and FirstNet? It's true! And guess what? There are shortcuts available that people aren't using! These tools have the potential to shave HOURS off chart review and clinical documentation. One of the most impactful ways you can reduce the amount of time you must spend in the electronic medical record, is to fully utilize the Patient Summary and its associated navigation tools. Patient Summary Overview 4 For many positions, the Patient Chart view will open to the part of the chart called, Patient Summary. The Patient Summary is organized in SBAR (Situation, Background, Assessment, & Recommendation) format. In addition, there is an Inpatient Summary and an Ambulatory Summary. Each tab (or MPage) contains a unique configuration of components that display important information from throughout the patient chart. 6 The components on each tab have been selected to provide you with the information you need to get a snapshot of the patient's clinical picture. In addition to providing you with the most recent results, many components also provide you with a direct link to the part of the record containing these and additional patient data. 7 Click the tabs at the top of the screen to switch between the various pages. 8 Many people find it helpful to "unpin" the Menu. Unpinning the Menu lets it "hide" until it's needed. This allows the selected link to expand to the full width of the PowerChart window. To hide the Menu, simply click the pushpin icon in its upper right corner. 12 The Inpatient Summary provides you with a synopsis of the available patient data from throughout the record. Most of the information found on this page is also found on the SBAR pages. 13 Most of the components on the Ambulatory Summary are the same as those on the Inpatient Summary. The most noticeable difference between the two pages is the timeframe selected for the various components. Page 1 of 10

2 Situation Background MPage 16 Allergies Component: As you can see, this page contains a component displaying Allergies. All active documented allergies will display here. Documented reactions will also display. Any allergies labeled Severe will appear in bold red font. Most components utilize hover functionality. Place the cursor over on-screen information to see additional details. Click the component header to go to the Allergies link. We have now navigated away from the Patient Summary to the Allergies link. To access the Menu when it has been unpinned, simply place the cursor over where it says "Menu." The Menu will open temporarily so that you can make a selection. 22 To return to the Patient Summary, you may also click the Back arrow in the upper left corner of the link. 24 Visit Summary Component: The next component to look at is the Visit Summary here in the middle of the screen. This contains the type of basic information anyone caring for the patient should know. 25 Flagged Events Component: At the top of the right-hand column is the component called, Flagged Events. When entering data into Interactive View and I&O, clinical staff have the option to "Flag" results. Flagged results will appear here, along with any accompanying comments. As you can see in this example, the nurse flagged the patient's initial Oxygen Saturation on presentation in the ED. 30 Vital Signs Component: This component contains three columns and will display the most recent results obtained today and then the two most recent results available within the selected timeframe. The timeframe is shown near the top of the component. The default look back timeframe for the Vital Signs component on the Situation Background page is one month. Page 2 of 10

3 30 You may click the dropdown arrow here to change the look back, as needed. 33 Hover over results for additional details. 34 Click to open the Result Details window. 36 Notice that in addition to showing details about the selected result, this window contains a "Trend" option. 37 Click Trend to see what additional results may be available for the patient. 38 The Result Details window for most Vital Signs and Laboratory tests has this option. It may be a helpful tool when trying to see patient results over time. 40 If you prefer visual aids over numbers, you may like this next option for finding patient trends. To see a line chart of the patient data, click the item name in the title column of the component. 42 For additional Vital Sign data, click the component header. 43 We are now looking at the Results Review link. Clicking the Vital Signs component header brings you here, to the "Vitals - Recent" tab of the Results Review link. 44 To return to the Patient Summary, click the back arrow in the upper left corner of the link as previously demonstrated. Another option is to use the history dropdown highlighted on-screen. 46 This feature allows you to jump to previously visited parts of the chart without having to skip through other links. 47 New Order Entry Component: As the name implies, the New Order Entry component can be used to enter orders. 48 Overdue Component: Below the New Order Entry component is Overdue Tasks. This component will display any patient care, medication, or other clinical task that has become overdue. 48 The component will display the date and time the task was due. 51 Orders Component: The Orders component displays orders that are active for the patient. 51 To see the full orders profile, click the component header. Page 3 of 10

4 55 Psychosocial Factors Component: This component contains information pertaining to the patient's psychological and social wellbeing. 56 Measurements and Weights Component: Measurements and Weights works similarly to the Vital Signs component. You may click an item name to view its available data in chart format. Like so many of the other components, the header will link out to Interactive View and I&O. 60 Lines, Tubes, and Drains Component: The Lines, Tubes, and Drains component will list which lines the patient has currently documented. This will include things like peripheral IVs, urinary catheters, and wound drains. 61 Hover over a line in the component to see its most recently charted information. 62 The header in this component will also take you to the Interactive View and I&O link. 63 Consolidated Problems component: Information about Diagnoses will appear in the upper section of this component and Problems (Active and Resolved) appear below. 64 Click the header to go to the Diagnoses and Problems link. 66 Intake and Output Component: Below the Lines, Tubes, and Drains component is Intake and Output. This provides a summary of the past 24 hours' I&O data. You may have noticed in some of the components above that there are these blue dividers. These separate data within the component and can be clicked to view additional information. 71 The Intake and Output component header provides another shortcut to the Interactive View and I&O link. Page 4 of 10

5 75 Procedure, Social, and Family History Components: First, note how the Procedure History component is collapsed? When you encounter a collapsed component, simply click the carrot icon on the right to expand it and view its contents. 77 Use the hover functionality to view additional details related to the documented procedural, Social, and Family History data. 80 Click the header of any of these three components to navigate to the Histories link. Assessment MPage 86 Like Situation Background, the Assessment page brings together data from throughout the patient's record. 88 Oxygenation and Ventilation Component: At the top of the column on the left is the Oxygenation and Ventilation component. This displays information pertinent to the patient's respiratory status and will include blood gas, respiratory measures and artificial ventilation settings, if applicable. This component has several sections, which can be opened to view available details. 89 Labs Component: The Labs component appears at the top of the center column, by default. This component has many of the same features as the Vital Signs component on the Situation Background page. 90 Hover over a result to see additional details. 91 Click a lab name to see a line chart and table. 92 Remember... The line chart will show you all results within the selected timeframe. If you want to pull in additional results, you will need to change the timeframe at the top of the component. 93 To change the timeframe, click the timeframe dropdown arrow below the component header. 95 Now, when you click the lab name you will see results for the new timeframe. Page 5 of 10

6 99 By default, the Labs component is divided so that the Primary Labs (those most frequently used by most caregivers) are at the top. 99 Below that, all labs will display. 100 You may collapse the sections to reduce the amount of scrolling needed. 103 The Labs component has additional filter options available. Note the dropdown tab highlighted on-screen. You may click this tab to see the available filters. 104 The default filter is called the "Facility defined view." Click the dropdown arrow beside this to see additional options. 105 As seen here, a number of filters have been configured. Let's select "Hematology and Blood Bank." 107 Some end-users prefer to have the Labs component default to one of the custom filters. To make it so that the selected filter will be the default Labs filter in the future, you may click "Set as default." 108 The "Reset All" options will reset the component to its original defaults. 109 Click the dropdown tab to close the filter options and view the selected lab results. 112 The filter has been applied. 113 You may not be surprised to learn that you may click the header of this component to go to the Results Review link. 114 Documents Component: The Documents component is next. 115 The Documents component allows you to access many reports, assessments, and notes. To change how far back the system looks to find documents, simply click the dropdown arrow beside the currently selected timeframe. 116 Use the hover functionality to see document details. Page 6 of 10

7 118 Click the document title to view the report. 119 The report will open in its own window. 120 Close the window to return to Patient Summary. 121 To select which documents to display, click the filter tab highlighted on-screen. 123 I'm going to choose the "Consultations" filter. 125 I'm going to now expand the look back timeframe. 127 Now, let's see what we've got! 128 As you can see, using the filters in the Documents component can be helpful when looking for specific document types. 130 If the available look back ranges do not meet your needs, or if you are not finding the document you are looking for... Click the component title to go to the Notes link. 133 Patient Assessment Component: The Patient Assessment component provides an overview of clinical assessment findings. Like so many other components, this one is divided into several sections. First is the General Assessment section. 135 Below that is the Pain section. In any of the sections, you may click a result to see additional details. 144 Click the component header to go to the Results Review link. 147 MAR Component: Next, let's look at the MAR (Medication Administration Record) component. 148 This shows medication administered over the past 30 days as follows: Scheduled in the next 12 hours, Continuous infusions, PRN/Unscheduled in the Last 18 hours, Administered in the last 24 hours, Suspended, and Discontinued in the last 24 hours. 150 Click the component header to go to the MAR link. Page 7 of 10

8 153 Diagnostics Component: The Diagnostics component will contain imaging and other test (e.g. EKG) reports. Use the timeframe filter to pull in more or fewer results, as needed. 155 Click the header of the component to go to the Results Review link. 156 Microbiology Component: The Microbiology component will display cultures in all statuses. Hover over a culture for additional details. 157 Click to see the report. 158 Microbiology reports will include results and antimicrobial susceptibility findings. 159 Click the header of the component to go to the Microbiology tab of the Results Review link. 160 Pathology Component: The final component appearing on the Assessment tab by default is Pathology. This works like the others, in that you may change the timeframe to expand the look back, if needed. This patient does not have any Pathology results, but if she did, we would be able to click to open the reports within the component. Let's click the header to see where it takes us. 162 The Pathology component header will bring you to this, the "Results - Recent" tab of the Results Review link. This tab will show you all lab, pathology, microbiology, provider reports, and imaging/test reports for the past 3 days. 166 The "Results - Extended" tab provides the same information over a six month period. Recommendations MPage 172 The Recommendations page contains three components: Plan of Care, Patient Education, and Discharge Plan. These pull forward patient data pertaining to these three things as it is entered into the patient record via various means. Page 8 of 10

9 Inpatient Summary MPage 176 Many of the components on the Inpatient Summary are the same or similar as those on the SBAR MPages. There are a few, though, that I'd like to bring to your attention. 177 Medications Component: This will display the medications the patient takes at home. You may hover over a medication to see additional details. 179 Click the header to view the list in the Medication List link. 182 Immunizations Component: 183 You will be able to see all vaccinations recorded in the Millennium EMR system in this component. MPage Customization You may click the header to go to the Immunizations link. 199 At this point, we've spent quite a bit of time looking at the various pages of the Patient Summary link. I'd like to pause to talk about your customization options. As you've seen, each page has its own configuration of components and default organization. However, you can change the layout of any or all of the MPages to meet your needs. Perhaps there are only a few components on the Inpatient Summary that are unique from the SBAR pages and you'd like to move these to the top so you don't have to scroll to find them. You can do this! All customization is done using the customization menu in the upper right corner of each MPage. 201 Instructions on how to customize your MPages are available through the Teach Me link. A supplemental interactive elearning course is also slated to be available in Page 9 of 10

10 Ambulatory Summary MPage 205 As mentioned earlier, the Ambulatory Summary contains most of the same components as the Inpatient Summary. The big difference between the Inpatient and Ambulatory Summaries Is that the look back timeframes in the Ambulatory Summary components tend to be longer and, therefore, will generally pull in more data. You may use whichever MPage best meets your needs. 206 At this point, we've reviewed the Patient Summary pretty thoroughly. You've seen how you can use this link to get a quick overview of the patient's clinical picture, as well as, to navigate throughout the record for more in-depth information. 208 That's it! As you've seen here, you can basically see just about all recent patient data right on a single link - Patient Summary. Not only that, but you can quickly access additional data right from there. So hide that Menu and try it out. Staff who have done so report significant time savings. Your time is precious. Make the most of it! Next up... What You Don't Know About Allergy Documentation. I'll see you there! Page 10 of 10