EDM 6 0 Training Manual by 1f54pC8

VIEWS: 74 PAGES: 80

									         MEDITECH

   EMERGENCY DEPARTMENT

       SYSTEM MANUAL

            NURSING
         REGISTRATION
       PATIENT CARE TECH
UNIT INFORMATION COORDINATOR
           PHYSICIAN
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                   JARRGON

   ADM: Admissions
   CPOE: Computerized Physician Order Entry – this will be house wide for
    physicians beginning August 2010, tentatively.
   EDM: Emergency Department Management – this includes all trackers
    and functions/routines for the Emergency Department
   EMR: Enterprise Medical Record – Viewing tool only.
   ITS: Imaging & Therapeutic Services
   PCS: Patient Care System – this includes trackers and functions/routines
    for all Inpatient areas
   PDOC: Physician Documentation – only ED Physicians will using the full
    Meditech System (documentation and order entry) initially
   POM: Physician Order Management
   Priority: Number assigned to patients, 1-5, dependent upon their level of
    illness – takes the place of the term “Acuity”
   Problem: Takes place of the term “Diagnosis”
   Public Tracker: HIPPA friendly version of Main ED Tracker – placed at
    Nurses Station and on middle wall for viewing by nurses, physicians,
    PCTs, and patient/family members
   Reception Routine: Used to receive patients into the system. DO NOT
    enter Reception Routine twice for any patient. Generates an account
    number each time it is accessed – takes the place of the F3 function used
    currently
   String: In Home Medication routine – the correct “string” has the
    Medication Name, Dose, Route, and Frequency
   Tracker: Status board showing each patient present in the ED. Shows
    patient status, reason for visit, pending orders.
   Triage Routine: Same information as on Reception Routine. Access the
    Triage routine when further information that was not added in Reception is
    needed.
   Worklist: All Care Items (i.e. Labs, Orders, Assessments, Treatments,
    Interventions) available for documentation on the patient




                                                                                      2
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                 SHORTCUTS

   F1: If unsure of the function of a particular button within EDM, place the
    cursor over the button and strike F1 which will provide an information
    screen
   F11: From Reception routine, performs Search – may use this in place of
    choosing Search
   F12: Saves information entered – may use this in place of choosing Save
   F9: Performs any lookup – may use this instead of selecting the down
    arrow in any look up field
   Tab: Takes cursor to the next section – may use this instead of scrolling
    with mouse
   Left/Right Arrow: Moves to the next answer within any section
   Space Bar: Selects the desired answer – may use this instead of the
    mouse to select appropriate answers
   T: T= todays date; T-1= yesterdays date, T-7= one week ago – this can be
    used in date/calendar questions
   N: N= now – this can be used in time questions
   Alt + F4: Closes open window




                                                                                      3
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                          INTEGRATED DESKTOP
                                All Care Providers




   Integrated Desktop is the default screen after logging into Meditech
   Top left corner is the Facility: SBHC indicates you are logged in at St.
    Bernards. Facility: CRCH indicates you are logged in at CrossRidge
    Community Hospital.
   This menu allows access to routines and functions to perform job
    requirements
   Back: goes back one menu
   Home: Goes back to home page
   Recent: The routines accessed during the current Meditech client session
   Frequent: View frequently accessed routines. This menu displays 20 most
    frequently used routines.
   Facility: Choose which facility you are working from (SBRMC or CRCH)




                                                                                      4
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0




                                 1   2   3 4 5

   1: Meditech Information Systems On-line Help
   2: Links to MissionNet and Micromedex
   3: Print page view
   4: Lock Session: temporarily minimize the session and lock it
   5: Email (not using)




                                                                                      5
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                          LISTS (EDM TRACKERS)
                                All Care Providers




   EDM Tracker provides a list of each area of the ED
   Main ED, Express Care ED, Triage are the trackers most commonly used
   Edit My List: allows viewing/editing patients associated to care provider
    currently signed in. Patients will only appear in this list if added by the
    care provider. Patients will only be removed from this list if removed by the
    care provider. Access this list by choosing My List from menu.
   Tabs on the right side of the screen (low lit buttons not available)
     Lists: page currently viewing
     Reassign ED Staff: allows the reassignment of patients, as a group, to
       another provider
     Calls: Radiology and Lab call backs (takes place of paper log)
     Reception: receive a new patient into the ED
     Indirect: N/A




                                                                                      6
    St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                     MAIN ED TRACKER
                                         Nursing, PCT, UIC




           The Main ED Tracker and Express Care Tracker are identical


                                             Header


1       2      3    4     5          6      7 8   9   10     11     12 13 14 15 16 17 18 19 20 21


           1: open chart
           4: “C” - confidential - if patient is confidential a purple Y will appear in this
            column
           8: priority level, previously named acuity level
           11: assign MD alternating. If the patient is to go to Express Care, an APN
            is also assigned (both names appear). If the Express Care provider is an
            MD, his/her name only will appear in this column.
           12: nurses, techs, and UICs should check Orders column frequently if
            yellow indicator is present.
           20: Blood Bank indicates if the pt has blood products ready to collect




                                                                                                7
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                 Detail Section




   Pulls additional data from selected patients chart for quick viewing
   Unnecessary for chart to be open to view Detail Section
   Room-Bed: for admit patients, information will be entered by Patient
    Placement when available
   Comments entered beneath patients name on Tracker can be
    edited/deleted from the “Comment” line in detail section
   Vital Signs: pulls latest set of VS recorded from the chart. Select the
    ellipses to the right of the recorded VS to see full set.
   Pain Re-Assessment Time: pulls from documentation of pain medication
    from the MAR. This time is not removed once pain is reassessed. It is only
    a reminder that reassessment needs to be performed.




                                                                                      8
 St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                 Right Side Tool Bar
                                    Nursing, PCT, UIC




* to choose any of the above options the patient you are inquiring about must be highlighted
             *the button that is highlighted is the area you are currently viewing

    Lists: ED areas to select for viewing, also Find Account option
    Tracker: Display of patients in current viewing area
    Clinical Data: “Ticket to Ride” and other information for ancillary
     department viewing. Also able to View/Edit Allergies and Home
     Medications from this area.
    Reassign ED Staff: Select multiple patients at one time and reassign to
     different care provider
    Patient Reports: ED Summary (choose this report) provides paper report
     in chronological order. Lists all Orders, Lab results, Notes, and
     Assessments. This will be used as the transfer documentation for patients
     being transferred outside the facility.
    Calls: Takes place of handwritten Culture and Radiology log books.
    Reception: Enter a new patient into the system. DO NOT enter Reception
     routine twice for any patient. Once all available information has been
     entered and Saved, any additional information given by the patient must
     be entered through the Triage routine. Training Manual.doc
    Triage: Same information as in the Reception Routine, but does not
     assign Patient Account number when accessed. This is not the Triage
     Assessment.
    Sign Up: Assign yourself to a patient after highlighting patient on Tracker
    Open Chart: Opens patients chart to the Worklist
    Close Chart: Closes chart
    Ready for Discharge: Button will remain low lit until patient is registered.
     Changes the status of the selected patient to “Ready Disch”. This can also
     be done manually by selecting status column on the Tracker.
    Indirect: N/A


                                                                                               9
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                Indicator Scheme




   A single checkmark is used for all pending orders/tests in the ED
   Yellow: Ordered/Uncollected
   Clear: Pending/Collected
   Green: Complete/Resulted


                                  Lower Tool Bar




   Refresh: Tracker refreshes every 60 seconds. If an expected update to
    patient orders/status has not taken place, use manual refresh.
   Add to My List: Highlight the patient’s name you are caring for and
    choose “Add to My List”. This places the patient in the “My List” option
    accessed from Lists. Patient will remain on appropriate Tracker.
   Add to My Team List: N/A
   Close All Charts: Only available for Physicians with multiple charts open.
   Edit Coverage: Allows selection of desired rooms for viewing.
   All: N/A
   (-): Decreases viewing size of Tracker
   (+): Increases viewing size of Tracker
   Show Empty Stations: View all empty rooms currently in the ED.




                                                                                      10
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                 Status Events




   Select patients current status (Status/Time column) to be prompted with
    list of all available Status Events
   Status Events changed manually from Tracker with exception of following:
         o Arrived: patient is entered into the system
         o Discharged: Discharge Date/Time is entered in Discharge routine
         o Ready Discharge: Ready for Discharge is selected by physician
         o RN Eval: Patient is placed in a room from Reception/Triage routine

                       Misunderstood Status Events

   Enroute: Must be changed manually when receiving an ambulance
   Provider Eval/in Rm: For MD and APN/PA
   Orders in Progress: Notify other care providers that orders are currently
    in progress
   Tx Wait: Anything the patient may be waiting on (Xray, Lab, RT, orders)
   CT #1/#1 Ready: CT will change this when ready for the patient
   In Radiology: Use for Xray, CT, US, MRI
   Room Ready: “Final Status Event” – removes patient from Tracker when
    room is clean


                                                                                      11
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                              RECEPTION ROUTINE
                              Registration and Nursing




   DO NOT enter this routine TWICE for any patient
   Most often will be entered by Registration unless a patient is called in by
    Ambulance, called to Triage booth before checking in with Registration, or
    taken directly to the back
   Enter this routine when the patient arrives to the ED, or when ambulance
    calls with patient report
   Initiate Reception routine from Lists or from Tracker (any)
   Enter all available information about the patient – the more information
    entered, the more accurate the Search will be
   Search every entry (select Search at bottom or strike F11 key)
         o If correct information appears in Search, choose this
         o If no matches available, select New Patient
         o If patient has been seen before but match does not appear in
            Search List, select Find More
   If receiving an ambulance, enter all available information. If name is not
    given, a first and last name must be entered (i.e. AMB,HEADACHE).
         o Enter as a new patient



                                                                                      12
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                     CONT.

       o Once the patient arrives, if the patient has been seen here before,
         immediately call Registration to enter correct information on this
         patient
       o Do not attempt to change the patients name or add/change the
         DOB once the patient arrives – call Registration for this change
       o DO NOT enter the Reception routine again once the patient arrives




   Complete all fields marked with an asterisk, and any others in which the
    information is available
   If a room is assigned (Area is automatically defaulted to ED Wait) during
    the Reception routine the patient will be placed on the appropriate Tracker
    with a status of RN Eval
        o If the patient is an incoming ambulance, after room is assigned the
            Status Event must be changed manually to “Enroute”
   Registration
        o ED Provider will be unknown, assign EMERGENCY,DR
        o After selecting Save, the following Warning screen will appear.




                                                                                      13
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                     CONT.




       o Chief Complaint may only be entered by an RN. Select Save and
         proceed.

   Nursing
       o If ED MD is known, assign them now. If not, assign Dr Emergency
       o If patient is present, proceed with Triage Assessment and
          Allergies/Home Medications as applicable
       o If entered information is for incoming ambulance, Save available
          information and wait for the arrival of the patient
       o A Chief Complaint must be entered in order to have any
          assessments and interventions populate to the Worklist for the
          patient




                                                                                      14
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                            ROOM ASSIGNMENT
                            Registration and Nursing




   Wait Areas
        o ED Wait and EC Wait
   Treatment Areas: Rooms to which patients may be assigned
        o Treatment Areas is the defaulted tab
        o ED Location: Choose either Express Care or Main ED
        o Count: shows number of patients in a given room
        o Max Cap: number of beds available in a given room – Max Cap is
           “1” for each bed, but multiple patients may be assigned to one bed
   Treatment Stations: Different view of each treatment area
   Treatment Groups: N/A
   Exclude Occupied: Removes all occupied beds from view
   Include Occupied: Lists all beds in ED
   Remember when bed or wait area is assigned to a patient, they will
    appear on the appropriate Tracker
        o Main ED beds: Appear on Main ED and All Locations
        o Express Care beds: Appear Express Care ED and All Locations
        o ED Wait: Appear on All Locations and Triage
        o EC Wait: Appear on All Locations and Triage


                                                                                      15
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                              TRIAGE ROUTINE
                                     Nursing




   This is not the short/long Triage assessment
   Find the patient (who has already been received) on the appropriate
    Tracker; Highlight their name and choose the Triage button from the right
    side Tool Bar
   Same information as Reception routine
   Complete any missing or invalid information from this screen (note the
    Chief Complaint, Area, and ED Provider are missing information or need
    to be changed)
   If the patient was received by Registration the Triage Assessment will
    need to be completed
         o Complete here, by placing a checkmark in the circled area
         o Triage Assessment may also be completed from the Worklist in the
            Open Chart
   Allergies/Home Meds can also be entered from the Triage Routine
   Once all information has been completed select Tracker from right side
    tool bar and return to the Tracker on which the patient was initially placed
         o If a room number is assigned the patient will be found on the
            corresponding Tracker


                                                                                      16
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                 ALLERGIES AND HOME MEDICATIONS
                                     Nursing




   Allergies and Home Medications can be entered/edited from four different
    locations:
        o Reception Routine
        o Triage Routine
        o Clinical Data (from Tracker)
        o Summary (from EMR in Open Chart)
   To enter a new Allergy or Home Medication, or to Edit/Review any
    Allergies/Home Medications that were previously entered on the patient,
    choose the blue Edit button




                                                                                      17
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                    ALLERGIES
                                       Nursing




      If the patient has no known drug allergies choose the NKA button
      If unable to obtain information from patient, EMS, or family choose the
       Unobtainable button until further information is available
      There are no longer abbreviations (i.e. PCN for penicillin)
      Type either the entire word or part of the word and strike Enter to
       receive a list of possible matches – if unsure how to spell the given
       allergy type only part of the word
      If the patient lists an allergy that is not found in the database, choose
       the Add as Uncoded button (circled) and proceed with entering the
       allergy




                                                                                      18
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                     CONT.




   Complete all fields marked with an asterisk
   Type should always be chosen as “Allergy”
   Status should always be “Verified”
   Reaction can be chosen from the drop down menu (F9), or may be free
    text if the reported symptom is not available
   The Comment field is used to add any additional information the pt
    provides about the given allergy
   If the patient has multiple allergies, it is not necessary to Save after each
    entry. Once all information has been entered select New at the top and
    proceed with next allergy. Save after all allergies have been entered.
   Audit: See all allergies that have been entered on this patient (history – if
    allergy was entered and then removed it will show in Audit). Also shows
    the person who entered each allergy.
   Snapshot: Different view of list of allergies.
   Remove
         o If not already Saved:
                 Place a check mark beside the incorrect allergy and select
                   Remove at bottom.



                                                                                      19
   St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                        CONT.

          o If Saved:
                     Place a check mark beside the incorrect allergy and
                        select Remove at bottom.
                     Receive a text box to enter a “Remove Reason”
                     Free text reason for this medication to be removed and
                        Save
      Verify: N/A
      Confirm
          o Patient has been seen in the ED previously and has Allergies
              already entered

              Patient with Allergies Entered from Previous Visit




          o Review listed allergies with the patient and assure they are correct
          o Place a check mark beside each allergy and select Confirm
Notice the Date column changes to today’s date




                                                                                         20
  St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                              HOME MEDICATIONS
                                       Nursing




*Example: Patient states has prescription for Lisinopril 10mg PO Daily but
 takes only half of a pill (5mg PO Daily). Today decided to take only 2.5mg
                          due to BP reading at home.

     If the patient takes no home medications, type the word “None” and
      choose the “Any Med” button
     Enter new Home Medications by typing name of medication in the
      “Medication” search box – each letter pulls medications that match
     If the medication is not found, or if the patient does not know name of the
      medication (i.e. “blood pressure pill”), type the name/type of the
      medication and choose the “Any Med” button
           o This adds the medication with no interaction check available
     ALWAYS select the plus (+) beside the name of the medication you are
      adding
           o This provides all “strings” for the given medication
           o Choose the “string” with most information available (ideally the
              Dose, Route, and Frequency of the med)



                                                                                        21
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                     CONT.

      o If the patient does not know the dose of the med, select the
         medication name only (not the “string”) – this adds the med with no
         interaction check available
   Choose desired “string” by selecting the correct line (i.e. 5mg PO DAILY)




   Information in the first blue area with Medication, Strength, and
    Dispense Form can not be changed manually. This is for the prescriptive
    portion of physician documentation only
   When the full “string” is chosen, all other information will default in and the
    only edit to be made is the Last Taken field
   Note the field marked with a light bulb (Instruction field):
        o This information is populated automatically when the “string” is
           chosen
        o This can be edited
        o If PRN is yes (Y), a PRN Reason must be chosen
   Date/Time can be entered with shortcuts (if Known is selected)
        o T= today
        o T-1= yesterday
        o N= now


                                                                                      22
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                     CONT.

        o 0800= 8am
        o Dose (marked with arrow) should only be completed if the patient
           took a dose different from the Medication dose entered initially
           (whether less or more)
   Note the asterisk (*) by Zocor. This indicates that the “string” was not
    chosen for this medication and will have no interaction checks performed.
        o If the information for this medication is not available (either by the
           lookup or by the patient) this is acceptable
        o If all information is available, please remove this medication and re-
           enter choosing the correct “string”
   If a medication was entered in error and has NOT been saved, place a
    check mark by the incorrect medication and select Cancel at the bottom
        o A cancel reason must be entered
        o On the edit screen, after cancel reason entered, note beside the
           medication the status has now changed to Deleted
   If a medication was entered in error and HAS been saved, place a check
    mark by the incorrect medication and select Discontinue at the bottom
        o A discontinue reason must be entered
        o On the edit screen, after discontinue reason entered, note beside
           the medication the status has now changed to Discontinued




                                                                                      23
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


         Patient with Medications Entered from Previous Visit




   In Home Medication routine, select Edit screen as above
   Verify with patient the medications have not changed
        o If no change choose all medications by selecting the yellow check
           mark
        o Select Confirm at the bottom
        o The Last Confirmed column will update with today’s date
        o The Status will change to Edited
        o Last Taken will also have to be answered for each medication
        o With all check marks still in place, choose Last Taken at bottom
           which will prompt following screen




                                                                                      24
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0




        o Use the cursor to navigate through the medications answering Last
           Taken on each
   If a medication is listed the patient no longer takes, place a check mark by
    the medication and choose Discontinue at the bottom
        o A discontinue reason must be entered
        o On the edit screen, after discontinue reason entered, note beside
           the medication the status has now changed to Discontinued




                                                                                      25
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                 OPEN CHART
                                Nursing, PCT, UIC




   Open the desired patients chart from the Tracker, the Worklist is defaulted
   View and Document Assessments and Interventions (Treatments)
   List of Care Items are suggestions of documentation pieces for the patient
    based on the Chief Complaint entered
        o If the chart is opened and there are no items in the Worklist, ensure
            a Chief Complaint was assigned during the Triage routine
        o Choose the Items that pertain to the specific patient
        o Every item does not have to be documented
   Determine Care Items vs Orders
        o All Care Items beginning with “ED” (excluding Triage and After
            Triage) are Chief Complaint specific. This means these are present
            for documentation if appropriate to the patient. These do not all
            have to be documented/completed.
        o Orders will not begin with “ED”, but may have “(Ed only)” at the
            end. Orders must be completed or cancelled. If an order is
            cancelled a prompt for a “Cancel Reason” will appear.
   Columns (Frequency and Status Due) are editable by selecting the
    corresponding table cell associated with the Care Item. Select directly on


                                                                                      26
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


    frequency or time (i.e. ONCE or -17m). If there is no information present in
    the given area select the empty area.
   Information ( ): Select this symbol and receive information on listed
    allergies, also height, and weight in kg.
   Include: Place a check mark in the boxes to be included on the Worklist
        o Interventions should always have a check mark in order to have
            Care Items associated on the Worklist
        o Medications is optional. If a check mark is placed here any
            medications ordered on the patient will show on the Worklist.
            Medications can NOT be documented from the Worklist.
   Care Item: Assessments and Treatments available for documentation
   Frequency ( ):
        o May be edited manually by selecting the empty area in the lookup
             (do not select the down arrow). Examples of frequencies: Q2H,
             Q15M, Q45M
        o Also editable by selecting down arrow and choosing from pre-
             existing frequencies
   Information ( ): Indicates the presence of associated data. Select the
    letter (i.e. ) and receive information associated with the Care Item
   Last Done: Displays the last time the Assessment or Treatment was
    documented. By selecting the time in this column, view item detail such as
    History (who documented this), and Flowsheet (complete documentation).
    Also able to Edit assessment from this area.
   Status/Due:
        o List of statuses are viewed by selecting the table cell in column of
             the corresponding Care Item
        o Three most commonly used statuses will be Complete, Inactive,
             and Cancelled
                 Complete: In order to complete orders the actual status
                    must be changed to “Complete”. Documentation of an order
                    or other Care Item does not complete the item automatically.
                    Only exception to this is Lab collection. Choosing “Complete”
                    in the status menu will cause the indicator to update
                    appropriately on the Tracker. However, if all orders have not
                    been changed to “Complete” the indicator will remain a
                    yellow checkmark indicating there are still orders to be
                    completed. Only “Complete” Care Items that will not be
                    documented again (i.e. Triage Assessment, After Triage
                    Assessment, Pelvic Exam, etc). If there are two items on the
                    Worklist that are the same/similar, document on only one
                    and complete both (i.e. ED IV/CVL Access and Saline Lock
                    Insertion – same assessment but Saline Lock Insertion is an
                    order vs ED IV/CVL Access is a Care Item associated with
                    the Chief Complaint – Once documentation of IV start is
                    complete (on either assessment), change the status of both
                    to “Complete” to remove them from the Worklist).


                                                                                      27
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                Inactive: Orders may not be inactivated. If a Care Item is not
                 going to be documented during the patients stay (i.e. ED
                 Pelvic Exam or ED Fetal Heart Tones on a male patient), it
                 can be changed to “Inactive” and will be removed from the
                 Worklist.
               Cancelled: Orders must be cancelled if not completed. After
                 selecting “Cancelled” a prompt for Cancel Reason will
                 appear. Answer appropriately.
       o Once the Assessment or Treatment has been completed, it will be
          removed from the Worklist. Use Change View tab to determine
          what items will remain on the Worklist.
       o The time in this column shows when the assessment or treatment
          is due dependent on the last documentation. A negative number
          shows the Care Item is past due.
       o The Emergency Department is not dependent on this time due to
          the fact that most assessments and treatments performed are
          STAT or ONCE orders.
   Today/Time & Now: Place check mark in the appropriate table cell
    corresponding with Care Item for documentation.
       o Select multiple assessments and/or treatments at one time for
          documentation
       o Now times the documentation for current time
       o Today/Time times the documentation for the time associated with
          that column

                                      Lower Tool Bar




   Refresh: Manually refresh Worklist to populate any recent orders placed
   Change View: Allows editing of which Worklist selections will appear on
    the Worklist.
       o Choose to have all completed and Inactive items appear at the
           bottom of the Worklist if desired
   Not Done: N/A
   View/Edit: View or Edit desired Care Items. Edit is only allowed on
    documentation completed by current care provider (may not edit other
    care providers documentation)
   Document: Select desired Care Item and choose Document
   Add: Add any Assessments or Treatments to the Worklist that are not
    currently present
       o Two options when Adding (Treatments or Assessments)
       o All Treatments and Assessments available for ED are named
           beginning with “ED”.



                                                                                      28
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


        o In Search box at top, type “ED” and strike enter. This will provide a
            list of all available Treatments or Assessments for the ED
        o If an item being searched does not appear in the list remember to
            change the look up (on the right side tool bar) from either
            Treatments or Assessments
   Utility: N/A

                             Right Side Tool Bar




   Tracker: Will take you back to the Tracker currently being utilized
   Select Visits: Allows viewing of all previous visits and diagnoses for this
    patient
   From Summary to Refresh EMR is known as the EMR. This is a viewing
    tool only:


                                                                                      29
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


        o Summary: Provides a Clinical snapshot of the patient including any
           diagnoses, active medications, allergies, home medications,
           pharmacy, etc. Also view demographics information on the patient.
        o Review Visit: Provides view of the Triage routine
        o Notices: Provides list of any notices sent to outside physician (i.e.
           Consult that was placed)
        o New Results:
        o Clinical Panel: View important pieces of patient visit (assessments,
           orders, medications, labs, etc) in a flow sheet format. Choose ED
           Visit Summary
        o Vital Signs: All documented VS
        o I&O: Display of any recorded I&O
        o Medications: MAR view of any active medications (ordered
           medications). Cannot document medication administration here.
        o Laboratory: If any lab results are available they are viewable here.
        o Microbiology: If any microbiology results are available they are
           viewable here.
        o Blood Bank: View available results for Type and Screen or
           Crossmatch
        o Reports: View physician documentation and radiology reports
           here.
        o Patient Care: View a list of the assessments documented for a
           patient, and to access the details of those assessments.
        o Notes: View any notes written by nurse, tech, or UIC
        o Refresh EMR: Manually refresh any information that has not been
           updated in the EMR.
   Orders: place orders on the patient
   Amb Orders: N/A
   ED Visit Data: View of the Triage routine
   Worklist: List of Care Items (defaulted when chart is opened)
   MAR: Medication Administration Record. Document medications given
    here.
   Write Note: Free text notes. Do not use this to document assessments
    which are available on the Worklist.
   TAR: N/A
   Discharge: Discharge routine. Print Discharge Packet here.
   Calls: Any calls made associated with this patient. This routine will be
    used by charge nurses to document any outside calls made for Radiology
    call backs or Culture reports. Also can document calls made to Nursing
    home for report.




                                                                                      30
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                              DOCUMENTATION

                                 Assessments
                                     Nursing




   The scroll bar at the top of the document is only present if the same
    assessment has been documented on previously. By scrolling to the left
    the previous documentation can be viewed for comparison if needed.
   Note the down arrow in the upper right corner. If the assessment was
    completed at an earlier time, the time may be edited here.
   Each assessment available for documentation will have a “Select All”
    section initially. The Select All section is a “normal” exam.
       o Select “Yes” and all answers in the Gastrointestinal Status box will
           default
       o If there was an abnormal portion of the exam, deselect that area as
           above (note the Bowel Sounds Present x 4 and Non-tender to
           Palpation are deselected) and document those abnormalities in the
           appropriate section of the assessment
   Remember that if the Select All “Yes” is chosen, this is documenting a fully
    normal exam. Do not enter contraindicating information further in the



                                                                                      31
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


   Assessment if there was an abnormal finding. Ensure that all abnormals
    were deselected in the “Gastrointestinal Status” section.
   When an assessment is initially opened, the only documentation that will
    be expanded is the Select All area
   Note the (+) and (-) boxes beside each section. To expand a section for
    documentation select the (+) box as is done with the “Abdomen” section.
   Note beneath “Bowel Sounds” the line stating “New Bowel Sounds
    Location”
        o This is an instance type
        o When an instance type is present, documentation may not take
             place until a body area has been selected.
        o Note there are no answers available for selection in the Bowel
             Sounds section
        o Select the appropriate body area by selecting the words “New
             Bowel Sounds Location“ (any instance type will always begin with
             “New . . . “) – if the (+) is selected it will only expand the section
             with no answers available (i.e. the Bowel Sounds section)
   Each assessment has a “Comment” section at the end. If there is any
    information that is not available within each of the provided sections, free
    text it in the comment section. Do not use the comment section to
    document the entire assessment. Answer as much as possible by
    choosing the answers available.
   Mode: Change how information is viewed or entered. By selecting Mode
    you will see only the selected answers instead of all.
   Hide Text: If there is any text associated with a question (that is part of
    Meditech – not the users documentation), selecting the Hide Text button
    will eliminate this from viewing.
   Recall: If same assessment has been documented previously, information
    can be recalled to populate current assessment, if nothing has changed.
   Edit: Allows editing of already documented assessment. Assessments
    documented by other users are not editable.
   Add Note: Add a free text note to be associated with this Assessment.
   Remember to always Save the documentation once complete. Either
    select the Save button at the bottom, or use the F12 key on the keyboard.




                                                                                      32
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                   Vital Signs
                                 Nursing and PCT




   Vital Signs assessment has two instance types to answer
        o Blood Pressure
        o Pulse
   Instance Types are always prefaced with the word “New” (note the arrows)
   No data may be entered until the Instance Type is chosen
   Once the Instance Type has been selected, subsequent Vital Signs
    assessments may be documented without having to choose an Instance
    Type unless needed
   Use the Vital Signs assessment to document bilateral arm pressures for
    Chest Pain patients who meet this criteria
        o Select the Right Arm (or Left) as Instance Type number 1
        o Once this has been selected, directly beneath the Blood Pressure
           documentation there will be a secondary Instance Type “New Blood
           Pressure Location” – choose the other arm here
        o Document both blood pressures




                                                                                      33
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                          Lab Specimen Collection
                                 Nursing and PCT




   Labs to be collected will always begin with “Specimen to Obtain:”
   To “collect” labs is to Document them from the Worklist
   Collect labs individually or collectively
   Do NOT document the labs until they are actually collected from the
    patient
       o Once the labs are documented, the lab labels will print and the
           “Specimen to Obtain” disappears from the Worklist
   Choose labs to be collected and choose Document




   Comment is used only if needed (i.e. to notify lab this is a redraw)
   Received Verbal Order From (Nurse): N/A
   Underneath Wound Culture, note “Source Unknown”
      o Select “Source Unknown” to document the body area
      o Urine Source must be chosen
   Underneath Blood Culture – Ed Only, note “Blood”
      o Select “Blood” to document the draw site for the blood culture
   Once complete, select Save at bottom of the full documentation screen




                                                                                      34
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                           EDITING AN ASSESSMENT
                                  Nursing and PCT

      The care provider may only edit his/her own assessment.
      Must be in Open Chart on the Worklist
      Two options for Edit




           o Highlight desired assessment on Worklist
                 At the bottom of the screen select the View/Edit tab. Do
                    not select the Document tab, this will only create a new
                    assessment.
                 The previously documented assessment will pull with all
                    previously chosen answers (appears just as the initial
                    assessment did).
                 Note the answers with check marks are low lit (unable to
                    be changed)
                 Place the cursor and select anywhere within the
                    assessment and note the Edit button at the bottom
                    becomes high lit.
                 Select Edit and continue with any necessary changes to
                    the document.


                                                                                      35
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                     The look up arrows in the upper right will only appear for
                      a time edit, after Edit is chosen.




           o Select the time in the last done column corresponding with
             assessment to be edited. This pulls the Item Detail screen
                 History tab is defaulted which gives list of all activities
                    regarding the assessment chosen.
                 To Edit from this screen the “Document” activity type
                    must be highlighted
                 Select Edit at the bottom and go directly into the
                    assessment to edit
                 Once edit is complete, note there is new activity type
                    directly below Document; “Edit Result” – in the Detail
                    section of this line select the flow sheet to view the old
                    and new documentation together.
                 If an assessment has been documented on the wrong
                    patient the option to Undo and Save is also available. If
                    selected, and Undo Reason must be entered.




                                                                                      36
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                PLACING ORDERS
                                   Nursing and UIC




        In open chart choose Orders tab on right side tool bar
        Three options available for placing orders:
             o New Orders: All orders aside from medications and IVF
             o New Meds: All medications and IVF
             o New Sets: Protocols
       Favorites: N/A for nursing. For physicians, once favorites have been
        selected and Saved, choose this tab to have all favorite orders appear
        for selection.
       Category Groups: Lists each Exam, Test, and Other Orders
        individually – Use this if unsure the name of a given test or order
       Name: Type the name of an order with a list generating from each
        letter entered
       Queued: Lists each order that has been selected and provides number
        of orders to be placed
       Multiple orders may be placed together. May also toggle between New
        Orders and New Meds before proceeding.
       If an order is not found change the view between Any Word and Starts
        With


                                                                                      37
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                       Ordering Provider and Source
                                 Nursing and UIC




   Verbal Order from ED physician
       o If the appropriate ED physician name is present select (highlight)
           that name
       o If the ED physician is someone other than the name present:
               Select the look up (down arrow) on Provider Group
               Choose EmCare from the list provided which will prompt a
                  list of all ED physicians
               Choose the correct ordering physician
       o Select only one of two options for an ED physician Source
               ED Only Telephone
               ED Only Verbal – most commonly used
   Order from non ED physician
       o If the appropriate physician name is present select (highlight) that
           name
       o If the appropriate physician name is not present:
               Select the look up (down arrow) on Other Provider
               In the text box type the appropriate physicians last name
                  which will prompt a list of all physicians with this last name


                                                                                      38
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


              Select the appropriate physician from the list
       o Select the appropriate physician Source
              Telephone
              Verbal
              Written
              Do NOT select the ED Only source for an outside physician
   Select OK after Provider and Source are chosen to proceed with orders

                                    New Orders
                                   Nursing and UIC




       Any orders, aside from medications, are placed under New Orders
       Multiple orders may be placed together
           o For physicians: If multiple orders are placed together, only
               necessary to PIN once for all orders.
       After selecting New Orders, select Name or Category Groups at top to
        begin placing orders
       Begin typing the name of the Order in the search box and a list will
        generate with each consecutive letter entered.
       Choose the desired order by placing a check mark in the selection box
           o Note this changes the Queue (now have 1 queued)


                                                                                      39
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


       To place multiple orders at one time
            o It is not necessary to select Next at the bottom to proceed with
               subsequent orders
            o Delete: Removes the last letters entered, individually, in the
               search box
            o Clear: Removes the entire word or group of letters entered
       Begin typing name of next order in the search box and follow above
        steps
       Once all desired orders have been selected choose Next at the bottom
        of the screen to proceed to the Manage Order List (verifies the
        previously selected orders)




   Three areas to verify:
       o Correct name of the order which was placed
       o Order has appropriate frequency (majority of orders placed in ED
           are defaulted to stat (STA)
       o There is nothing to be edited (needed edits will have an asterisk in
           front of Edit)
   Order List: Lists all orders to be placed
   Notify: N/A



                                                                                      40
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


   Conflicts: Lists any conflicts with orders being placed (i.e. if a CBC had
    been ordered on this patient previously and is again being ordered here
    there would be a ”Duplicate Order” conflict to be resolved.
   Details: Lists details of given order including all edit choices selected
   Edit All: If multiple edits are needed select Edit All without having to edit
    each order individually

                                      Edits
                             Physician, Nursing, UIC




   Edit Order
       o An edit button with an asterisk (      ) shows there is a required edit
           for this order
       o Without completing necessary edits, Saving the order is not
           possible. OK button in bottom right of screen will not be available
           for selection.
       o “**Complete Only if Orders was not Received by Ordering
           Physician**”
                This statement is referencing the section below it, “Received
                   Verbal Order from (Nurse):



                                                                                      41
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                This will only need to be completed if a verbal or telephone
                 order was received from another nurse representing a
                 physician. If this occurs, place the name of the nurse giving
                 the order in this box.
       o Any radiology exam entered outside of an Order Set (protocol)
         must be edited
              ITS Site – SMBC
              Reason(s) for exam – Must use answers provided in look up.
                 May free text part of a provided answer (i.e. “shor” for
                 Shortness of Breath, or “che” for Chest Pain)
                  After the ITS Site has been selected on the initial
                    radiology exam for the patient, it will not be required for
                    any subsequent exams.
       o Once all edits are completed select OK which will prompt a final
         verification screen (below)




   If any orders are incorrect or should not have been placed, use the Edit
    Multiple button to edit or cancel the order
   Before selecting Save, all order statuses will show “New”
   If all is correct, select Save and new order statuses will be reflected



                                                                                      42
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                   New Meds
                                     Nursing

   Proceed using same steps as placing a New Order
       o Select Orders from right hand tool bar
       o Select New Meds
       o Choose Provider and Source, select OK
       o Proceed with entering order in the text




   Lookup will pull medication matching each letter entered in the search box
   Lookup defaults to “Starts With” – if a medication is not found, select “Any
    Word”
   All “strings” available for a medication will appear; select the most
    appropriate
        o To order Morphine 2mg IV select the morphine SULFATE IV route
        o If a check is placed by the name morphine SULFATE, when
             proceeding to next screen all available forms and doses will be
             listed to choose from – to avoid this select the desired route
   Select Next to proceed to Manage Orders screen




                                                                                      43
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0




   Dose, Route, Frequency, and Schedule (SCH) are editable in two areas
        o Select directly on the number associated to the dose (2), on the
           route (IV), on the frequency (ONCE), or on the schedule (STA) to
           edit from Manage Order List
        o Select edit (      ) and make necessary changes from Edit routine
   Ensure the schedule is correct
   Once order has been verified select OK and proceed to Current Orders
   If order is correct, select Save at bottom




                                                                                      44
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                   New Sets
                                 Nursing and UIC

   Proceed using same steps as placing a New Order/New Med
       o Select Orders from right hand tool bar
       o Select New Sets
       o Choose Provider and Source, select OK
       o Select Category




   Specialty Order Sets lists all order sets available house wide including
    medication protocols/order sets




                                                                                      45
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


   Select the (+) beside Emergency Department to view all sets available for
    ordering
       o Select desired Order Set
       o All orders associated with this order set will automatically generate
           without selecting Next




   Order Sets will generate with most orders defaulted aside from
    medications.
   Not all orders are pre-selected (i.e. Bilateral arm pressures and Bedrest
    on Chest Pain protocol), therefore they should still be reviewed.
   Radiology exams do not require an edit when in an Order Set
   Consults will always require an edit, even in an Order Set
   Review orders and select OK
   Verify orders from the Current Orders screen and select Save




                                                                                      46
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                  ADMINISTERING MEDICATIONS - MAR
                                     Nursing




   Access the MAR from the Open Chart on the right side tool bar
   Note beneath patient name “Patient Verified”
        o Patient has been verified either by BMV scanning
        o Or by manual verification when administering medication
   Include
        o Active: View all medications that are currently active
        o STAT/ONE: View only stat or once medications
        o IVs: View only IV medications
        o PRNs, Pending, Discontinued: View only medications in each of
           these statuses
   Start/Stop time reflects when the order was placed and when it will
    discontinue (for stat drugs this is after 1 minute – or once it is
    administered)
   Medication (Route): All ordered medications will appear here with the
    given information:
        o Trade name
        o Generic name
        o Dose, Route, and Frequency



                                                                                      47
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


       o    Information icons
       o    Administer amount (Give:): if dosed from a vial
       o    Total Volume and Duration: for IVF fluids (including piggy backs)
   Time: time the medication was ordered
   Date: this is determined in the Change View tab. The default is set to
    display dates 7 days in the past and 1 day in the future. Use the scroll bar
    to look at all dates present.
   Icons
        o Monograph ( ): Provides medication detail in English and
            Spanish. May be printed for the patient.
        o Flowsheet ( ): Provides information charted about the
            medication. Pain medications require a pain scale, IM medications
            require an injection site, medications that may decrease BP require
            a recorded BP before administration is allowed.
        o Special Instructions ( ): Enter any text that should be known
            regarding the drug to be administered
        o Order Conflict Flag ( ): Provides information if the medication
            conflicts with patient allergies or home medications, or against
            another ordered medication.
   Refresh: Manual refresh if medications have been ordered but have not
    appeared on the MAR
   Change View: Change the time interval the medications are displayed in.
    The default is set to display dates 7 days in the past and 1 day in the
    future.
   Document: Document medication manually
   Document Unsched: Allows documentation of PRN medications and
    scheduled medications which are not due
   Deatil: Provides information on medication detail
   Manual Barcode: N/A
   Renewal Sch/Freq: N/A

       Beside Medication Verification (BMV) and Administration
                                     Nursing

   Each room is equipped with a BMV scanner
   When preparing medication for administration (all routes), DO NOT
    discard the container the medication was in. Take the vial/packet into the
    patient room.
   As a rule of thumb, "If there is a barcode on the medication, scan it."
   Medications with barcodes on the unit to administer:
        o Tablet and capsules
        o Oral liquids
        o Vials and syringes
        o IV bags
   Although ampules have barcodes on them, it is unsafe to handle the
    broken glass. There is not an expectation to scan ampules.


                                                                                      48
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


   Medications that may not have a barcode on the unit to administer:
       o Ointments and creams
       o Suppositories
       o Inhalers
   Scanning (BMV)
       o In the open chart, access the MAR for the patient
       o First scan the patients arm band – this verifies the patient
       o Once the patient has been verified it is not necessary to scan the
          armband for subsequent medications if all are administered in the
          same session. If for any reason the chart is closed or the patient
          room is left it will be necessary to rescan the patient armband on
          returning/reopening the chart
       o Next, scan the medication container which will prompt the
          documentation screen




       o Dose in mg is defaulted to what is ordered. This should only be
         changed if less than ordered dose is given.
       o If giving a pain medication, an IM medication, Tetanus, or any
         medication that could decrease blood pressure, Flowsheet will
         appear in red showing further information must be documented.
       o Select Flowsheet and complete
             o Five flowsheets available for documentation




                                                                                      49
    St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


*Pain Med Admin




*Blood Pressure




*Last documented BP will default here. If from an extended time ago delete and recheck BP.

*Tetanus Vaccine and Intramuscular Injection Site




*IV Fluid




*Must answer the first two questions. “Is This the First Bag”: yes for initial bolus and no for
subsequent boluses. Once bolus is complete, Edit Full Assessment and document the time in
“Time Bolus was Completed” section

            o Once information has been completed, proceed with scanning any
              additional medications the patient is to receive

                        Manual Verification and Administration
                                             Nursing

       In open chart access the MAR




                                                                                                  50
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


   In the Today (date) column select the Time (i.e. -24m) in the table cell
    corresponding with the medication to be given which prompts this
    administration menu




       o Given: Documents the medication at the time it was ordered (can
           be edited)
       o Not Given: A non-admin reason must be entered if the medication
           was not given to the patient.
       o Document: Documents the medication at the current time (can be
           edited)
       o Edit Assessment: (medication must be administered) Allows editing
           of the Assessment Flowsheet if needed – this would be used to edit
           level of pain after a pain medication administration or to document
           to the time a bolus was completed for an IVF bolus
       o Full Edit: Allows editing of entire medication administration – this
           would be used if incorrect time was documented or if dose was not
           changed
       o Undo: Removes documentation of administration of this medication
   Select appropriate Administration method
   Complete Verification screen (select Manual Barcode) with the patients
    account number (SV number) – must type “sv” in front of the number




                                                                                      51
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0




   Select OK and proceed to Medication Administration screen




   Dose in mg is defaulted to what is ordered. This should only be changed if
    less than ordered dose is given.




                                                                                      52
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


   If giving a pain medication, an IM medication, Tetanus, or any medication
    that could decrease blood pressure, Flowsheet will appear in red showing
    further information must be documented.
   Once all information has been completed select OK to return to the MAR
    and continue the documentation of subsequent medications




                                                                                      53
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                              VIEWING THE EMR
                         Nursing, PCT, UIC and Physician




   See page 28 of user manual for explanation of each tab in the EMR
   Tabs that contain results that have not been viewed by the user will
    appear in read as a notification. Once viewed the lettering will change to
    black
   Low lit tabs have no information behind them




                                                                                      54
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                  New Results
                              Nursing and Physician




   New Results will show any lab results, physician documentation, and
    radiology results within the last 48 hours. The word “New Results” will be
    red if there are any new results which have not been viewed.
   The labs will appear in columns extending to the right depending on the
    times they were resulted.
   To view the reports that appear, select the clipboard beneath the Rpt
    column.




                                                                                      55
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                Clinical Panels
                        Nursing, PCT, UIC, and Physician




   Select ED Visit Summary
   Numerous assessments and treatments are viewable in a “snapshot” form
    in Clinical Panels, including (but not limited to):
        o Triage/After Triage assessments
        o IV starts
        o Physician documentation
        o Any reports generated (radiology, microbiology, etc)
        o Medication administered
        o Lab results
        o Vital Signs
        o Nursing Notes
   Labs: select a lab result to view normal range
   MD reports, radiology reports, nursing notes: Select the clipboard to view
   Medications: Select dose to view when medication was given and by
    whom
   Any information may be selected to view all documentation (i.e. within
    Peripheral IV/CVL Access/DC note “Initiate Per…” – to view all
    documentation select the words)


                                                                                      56
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0




                                   Vital Signs
                        Nursing , PCT, UIC, and Physician




   Abnormal vital signs will be highlighted in yellow
   Select any value to view normal ranges for that component

                                  Medications
                              Nursing and Physician




   View all medications that have been ordered on this patient
   Same information that is on the MAR
   Unable to document medications from EMR
   Can also change to the MAR view by selecting the MAR button at top




                                                                                      57
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                  Laboratory
                        Nursing, PCT, UIC, and Physician




   View all resulted labs
   All abnormal results are highlighted yellow with an “L” or an “H”
   If a comment bubble is present ( ), there is information entered by lab
    personnel regarding this lab result
   Switch between different panels using the buttons along the top of the
    panel (i.e. Hematology, Chemistry, Urines)

                                    Reports
                           Nursing, UIC, and Physician




   Switch between categories using buttons along the top of the panel
   Select the clipboard beneath “Rpt” column to view repot



                                                                                      58
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                  Patient Care
                        Nursing, PCT, UIC, and Physician




   Select the desired Assessments or Interventions for viewing by placing a
    checkmark beside each
   To select all, select the yellow check mark at the top
   Outcome: N/A
   Plan of Care : Lists all orders, assessments, and interventions for the
    patient, also what status they are in
   History: Pulls positive information (i.e. any PMH, immunizations, etc) for
    quick viewing
   Scanned Form: N/A
   Surgery Assessment: N/A
   Date, Name, Recorded By, and Provider Type: Use these to sort the
    Assessments/Interventions

                                      Notes
                        Nursing, PCT, UIC, and Physicians




   Lists individually all free text nursing notes that have been entered
   Select the text in Text column to view note alone
   To view all notes together place check mark in each box and select OK at
    the bottom
   Notes will appear in reverse chronological order

                                 Refresh EMR
                        Nursing, PCT, UIC, and Physicians

   Select Refresh EMR if waiting for results/reports to cross to the EMR



                                                                                      59
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0




                                 DISCHARGE
                                     Nursing




   Most discharge information will be completed by the physician (i.e.
    instructions, prescriptions, referrals, and additional text.) If there is
    information missing it can be added here.
   Discharge Plans
    o Instructions
            The instruction that is defaulted in is based on Chief Complaint
            To remove a set of instructions, highlight the instructions and
               select the “x” that is circled in the bottom left
            Select the down arrow (look up) to select further instructions
            Instructions are defaulted to Current Complaints
            Select the tab Lookup which will provide a list of all available
               home instructions for the patient




                                                                                      60
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0




              Begin typing part of problem (diagnosis) or complaint in the
               search box to find patient instruction
              Select the appropriate instructions and choose OK at the bottom




   o Stand Alone Forms
      Select the down arrow (look up)
      Choose Return to Work/School and OK
      Return to Work/School excuse populates the Discharge Plans
        Screen
      Select the edit (  ) button




          May only provide work/school excuse for up to 3 days
          Select the down arrow (look up) to select number of days
          Free text any additional instructions
          Choose OK when complete


                                                                                      61
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


o Referrals
      Select the down arrow (look up)
      Search is defaulted to All Providers
      Type the physicians last name and select appropriate physician
        from list
      To enter a follow up with “PCP” or “Family Physician” select the
        Other Referral tab from the right side tool bar and complete
        information appropriately
      Once information is complete select OK




       o From the Discharge Plans screen, if the referral needs to be edited
         select the clipboard/clock ( ) and complete needed information




                                                                                      62
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0




   Discharge Data
        o Discharge Date/Time
                This time can only be entered on a fully registered patient
                Once this time is placed the patient will be removed from the
                  Tracker
                Do not enter the Discharge Date/Time until the patient has
                  been discharged, left the room, and the room has been
                  cleaned
        o Discharge Disposition
                This field is a look up, choose disposition appropriately
        o Discharge Problem (diagnosis) is entered by the physician
        o Discharge Record
                This includes discharge information such as discharge
                  instructions given, prescriptions given, IV removed, driving
                  instructions
                Place a check mark in the box and select Document at
                  bottom to document discharge for the patient
   Once all information has been completed select Save at the bottom and
    return to the Discharge Plans (button at top)




                                                                                      63
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


   From Discharge Plans screen, select the Print Packet button




   This will print the patient discharge instructions, work/school excuse, and
    signature page
   Print Packet does NOT discharge the patient; the patient is only
    discharged after entering the Discharge Date/Time
   Discharging a patient who does not immediately leave the room or the
    room is changed to Housekeeping
        o Complete all information as described above
        o Do NOT enter a Discharge Date/Time on Discharge Data screen
        o Print the patient discharge packet
        o Have patient sign appropriately and discharge as usual
        o Manually change the patient status to Housekeeping on the Tracker
        o Once the room is clean and ready for the next patient, reenter the
           patients chart and enter the Discharge Date/Time to remove the
           patient/room from the Tracker




                                                                                      64
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


               MEDICATION RECONCILLIATION REPORT
                                 Nursing and UIC

   Access the Home Medications Routine from either of the four areas
       o Reception Routine
       o Triage Routine
       o Clinical Data (from Tracker)
       o Summary (from EMR in Open Chart)
   Enter Home Medications by selecting the Edit button (       )
   Select Print at the bottom which will prompt the following screen




   Select the appropriate Med Rec Report and choose Print at the bottom




                                                                                      65
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


             CULTURE LOG AND RADIOLOGY OVERREADS
                                     Nursing

   Access from Tracker
   Defaults to Call Backs (calls which have been entered previously)

                                     New Calls




       Each text box is a look up field, select the appropriate response
       Date/Time automatically populate
       In *Patient field type the patients name and perform Search
       In Subject/Summary of Call text box type anything that is pertinent to
        the culture or rad report
       Select Save




                                                                                      66
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                       PHYSICIAN DOCUMENTATION
                                 Main ED Tracker

   Sign in to Meditech and choose EDM Tracker
   From Lists screen choose desired Tracker for viewing




   When the Tracker is open it is sorted by Department Time
   May be sorted by Room Number or by MD (the above Tracker is now
    sorted by MD)
   By highlighting a patients name on the Tracker view pertinent information
    in the Detail Section at the bottom
   The right side tool bar has the same information present as nursing with
    the exception of Sign and Ready for Discharge




                                                                                      67
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                 Side Tool Bar




   Sign
       o Electronically sign charts
       o The Sign routine will appear in red lettering if there are orders or
         documents which need to be signed
       o If the function is selected while viewing a patient in the Physician
         Care Manager it will only populate orders/documents for that
         patient
       o Access this function without a pre-selected patient and view all
         unsigned items
       o Select Sign from the right side tool bar




                                                                                      68
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0




       o The Notes tab will not be available for signing
       o To choose all, select the yellow check mark at the top left; To select
         only certain documents or orders place individual check marks next
         to the appropriate items
       o Select             at the bottom and proceed with the E-sign process




       o Sign
              This marks document for a signature
       o Edit Document
              Generates the documentation for the given report and allows
                editing of any information present.
              Each physician may only edit documents created by himself
              Documents may NOT be edited once signed; if any changes
                are to be made an addendum to the chart must be created
       o Edit Other Signers: N/A
       o Prior/Next
              Navigate through all documentation for review before
                selecting Sign




                                                                                      69
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


       o Stop
             Stops the viewing process and proceeds to sign only the
              documents that have been marked to sign
            




       o Select Sign




      o Enter PIN number and strike Enter key
      o This will prompt back to the initial View & Sign screen
      o Select Tracker from the right side tool bar to return to Main ED
         Tracker
   Ready for Discharge
      o Patient must be registered
      o Highlight patients name on the Tracker
      o If all documentation is complete select the Ready for Discharge tab
         on the right side tool bar and this will change the patient status to
         “Ready Disch”
      o Status may also be manually changed from Tracker




                                                                                      70
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                 OPEN CHART




   May have up to five charts open at one time
   Open Chart defaults to the Activity Screen
      o Activity screen is defaulted to All, but may be changed manually
          depending on desired viewing
              All: Lists all Assessments and Treatments completed – items
                are listed in reversed chronological order
              Providers: Lists the nursing staff caring for the patient
              Complaints: Lists all Stated and Chief Complaints
              Interventions: Lists only the Assessments and Treatments

       o                             By selecting the comment bubble see what
           part of the patients chart this information was completed (Triage,
           Worklist, or Discharge




                                                                                      71
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                      EMR

   The EMR is identical in all applications (nursing and physician) as
    discussed previously in the manual. Please see pages _______.

                                     Orders

   Physicians will proceed with orders in the same manner as discussed
    previously in the manual. Please see pages ________.
   Physician Favorites were created as the default screen when the Orders
    routine is accessed




   Choose from any orders listed by placing a check mark in the Frequency
    box (Stat)
   If an order does not exist in the Favorites list, select the Name tab and
    proceed as previously described in the manual
   When all desired orders have been chosen select Next and proceed to
    Current Orders screen



                                                                                      72
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


   All new orders will have a status of “New” in green print
   If Orders are correct select Save




   Enter Pin number for orders to be processed
   Pin orders
       o Each order does not need to be pinned individually
       o If multiple orders are placed in one session enter Pin once for all
       o Once orders have been pinned, if further orders are placed, the Pin
           must be entered again




                                                                                      73
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                     HOME MEDICATION RECONCILE
                               Orders

   From Open Chart routine select the Orders tab
   From Current Orders screen, select Reconcile at bottom which provides
    list of Home Medications




   Three options exist in Status column
       o Cont
               Creates an active order for the exact dosage and frequency
                 of the Home Medication listed – i.e. Hyoscyamine 0.125mg
                 po at 0600, 1400, and 2200 would be ordered
               If Cont is chosen the Medication will turn to green lettering
                 which allows editing of the Dose, Frequency (change to
                 Once) and Schedule (change to STA)
       o Pt’s Own
               Patient may take own Home Medication if available
               This acts in the same manner as selecting Cont by creating
                 an active order for the exact dosage and frequency
               Edit as described above
       o Hold
               Does not create an order for the Home Medication
               By selecting Hold, this acknowledges the Home Medication
                 List has been viewed and reconciled during the patients visit
   Select Save at bottom when Reconcile routine has been completed




                                                                                      74
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


         RENEW, DISCONTINUE, or CONVERT MEDICATIONS
                         Amb Orders

   From Open Chart routine select the Amb Orders tab
   The Convert screen is defaulted




   Use the Convert routine to convert Home Medications to prescriptions
   Emergency Medications
       o This lists all drugs which have been ordered on the patient
       o These can be changed into Prescriptions in three ways
              Select the name of the drug - this gives all forms of the
                 medication
              Select the dose of the drug
              Select the prescription line of the drug
              Each of these can be edited accordingly by selecting the edit
                 button or by selecting directly on the dose or frequency
   Emergency Orders: N/A
   Ambulatory Orders
       o List of the patients Home Medications
       o Category
              Rx: Medication has been changed to a prescription

                                                                                      75
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                  Patient History: Medication was entered as a Home
                   Medication
       o Status
             Active: This is a current medication for the patient – select
                the word Active for more options
             Cancel: Use this if a patient reports that they do not take this
                medication at home (if the nurse entered the medication in
                error). This will remove the medication from the Home
                Medication list
             Discontinue: The patient should stop taking this medication
                at home
             Renew: Converts the Home Medication (as entered by the
                nurse) into a prescription




                                                                                      76
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                              DOCUMENTATION

   Documentation Auto Saves every 2 minutes
   Quick Save saves to a draft status and closes the document
   View and Save allows viewing in report format and Saving to a draft status
    or Signing the document




   Information that is documented by the nurse will pull into the physician HPI
    (i.e. description/onset of symptoms and all triage information, PMH, PSH,
    Social History)
        o It is still necessary to review this information for any missing
            information or errors
   The most recently documented vital signs populate at the bottom of the
    screen for viewing




                                                                                      77
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0




                                  Add Section




   Add associated sections to any documentation template if it is not already
    present
   Select Add Section at bottom of template which provides this list of
    associated sections to choose from
   Select the desired template and it will populate to a body button at the top
    of the Documentation screen




                                                                                      78
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0


                                      Exam

   Documentation has the ability to “circle all” for positive responses and
    “slash all” for negative responses
   Also select individual responses with the left click=circle and the right
    click=slash
   Once a response is chosen the comment field at the bottom is available
    for any additional comments regarding this response
        o Once a comment has been entered, the corresponding response
           will have a yellow comment bubble

                                      Notes

   The Notes body button at the top of the documentation allows free text
    notes to be typed

                                   View/Save

   Allows viewing of the documentation in a report format


                                   Departure

   Multiple diagnoses may be entered via free text
   Select the down arrow for the Instructions line to choose the appropriate
    Discharge Instructions for the patient
   Note on the Instructions line the text states <Entered> - this shows there is
    information present





                                                                                      79
St. Bernards Medical Center Emergency Department / Meditech User Manual Version 6.0




                                                                                      80

								
To top