University of Toledo Medical Center Emergency Department Horizon by pyw18970

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									University of Toledo Medical Center 
Emergency Department 
Horizon Emergency Care Training 
Manual for Physicians 
 

 




                                        

                       

                    2008 
 HEC Physician Charting Class Outline 

Part 1 – Choose your patient 
  1. Sign on the tracking board

  2. Choose the right patient by clicking on patient on the tracking board.

  3. Assign yourself to patient by clicking in the MD column

  4. Optional click chart view of highlighted patient. And print … this gives you a
     paper face sheet for notes if needed

  5. Click on chart on the tracking board tool bar


Part 2 – Evaluate the patient 
  1. Read the nursing note (“review and agree is the same as you did it”) – This is
     needed for coding.

  2. Time stamp the chart

  3. Evaluate the patient

  4. Choose the correct chief complaint
        a. No need to delete incorrect chief complaints
        b. Medical vs. trauma (trauma = yoga person)
        c. Local vs. systemic problems (local= yoga person)
        d. Equivalent to choosing the correct ‘T” sheet or Lynx Form

  5. Optional: Enter all orders now see below or proceed to charting H/P


Part 3 – Do a History & Physical 

  1. Enter your History and Physical Exam

  2. Systematic approach avoids going back at the end to complete charting

  3. Typical history screen
          a. Top line is common problems, with classic presentations
          b. Turn on and off answers
          c. If the question sets don’t make sense, you have the wrong Chief
             Complaint
          d. Document what you do and NO MORE
          e. Most of the relevant review of systems are in the history
          f. May document multiple chief complaints if necessary

   4. 12. PMH/FH/SH/ROS

   5. Read the nursing note and agree, no need to repeat

   6. “all else negative and FH not relevant on every case”

   7. Only need one or two from social history

   8. Physical Exam
         a. Quick click” most of the time
         b. Soft tissue exam for trauma and injuries.

   9. Major trauma survey


Part 4 – Enter orders 

   1. 14. Orders (if not already entered)
          a. Try ED ala carte’ set first or problem-based ordered sets
          b. Body figure for local orders
          c. Avoid free text - If you can’t find an order use the miscellaneous ED
             order sheet (paper) and give to the ED clerk. They will place the order for
             you and Clinical Informatics will build it so its in the system for next time
          d. Canceling orders from “ signed off orders”
          e. Follow up questions for IV, x-ray, etc


Part 5 – Things to do during the patient evaluation & 
treatment 

1) Updates
   a) Quick general update
   b) Discussions
      i) Private MD or consultants
      ii) Family or patient
       iii) Turn over patients under this heading

2) Importing Labs
   a) Click on labs to import into chart and review

3) Document monitor and EKG
   a) I would do this at the time you read the EKG or change the time stamp

4) X-ray
   a) You have to remind the computer what x-ray was ordered
   b) If you make your clinical decision based on your interpretation you are the
      Primary viewer.

5) Procedures
   a) Remember to do the procedure first then document.

6) Write your Rx
   a) Work notes and school notes are under my personal Rx


Part 6 – Disposition the patient 
1) Disposition
   a) Choose your primary diagnosis
   b) Systematic approach to discharge screen
   c) Review level of charting and correct as needed
   d) Choose discharge instructions
   e) Choose follow up physician
   f) Choose your disposition
   g) Auto sign all orders
   h) Sign the chart (and choose cosigning provider if mid level)
   i) DON”T SIGN THE RN CHART….

2) Printing
   a) Can be done from dispo screen or main chart

NOTE at the end of your shift go to CHART FINDER, search for your unsigned charts
and sign them

For the chart to be sent to Horizon Patient Folder and billing you must have signed the
chart.


Part 7 – Teaching Physician steps 
   1. If you are a Resident, Medical Student, PA or NP
       a. Choose the attending physician
       b. Go into the CONSULT section of the chart and choose “Discussed case
          with ER Attending

2. If you are an Attending overseeing a mid level provider
       a. Go to the CONSULT section of the chart
       b. Choose “Have reviewed the ER Record”
       c. Choose “Medicare Standard agree Statement”
       d. Choose other choices that are pertinent.
    Emergency Department Tracking Board
           TRAINING MANUAL
                                          Version 1.0 – 2008




                            Basic understanding of the
                   McKesson Emergency Department Tracking Board




University of Toledo Medical Center – Horizon Emergency Care Nursing Training Manual   1
  Introducing Horizon Emergency Care (HEC) Tracking Board
   •    Replaces the magnet / whiteboard in the Emergency Department with an electronic one.
   •    Main screen to manage patients and care flow within the Emergency Department
   •    Launch point into the Emergency Department Electronic Medical Record (EMR) and
        documentation
   •    Assign patients to beds
   •    Physician, Nurse & Tech patient assignments
   •    Links to order entry & management prior to going live with Horizon Emergency Care
        documentation and orders
   •    Document Problems, Allergies and Medication (PAM) history
   •    Shows status and location of the patient at current time
   •    Displays status of laboratory and other results
   •    Links to web page resources, the Clinical Portal, Micromedix, Clinical Informatics web site,
        etc.
   •    Dispositioning of patients off the tracking board
   •    Maintaining logs of various events throughout the patient care in the department to help
        identify bottlenecks, reporting,




Contents 
    Basic understanding of the McKesson Emergency Department Tracking Board ................................. 1 
  Chapter 1 – Logging In: Accessing the Tracking Board through PC View ...................................................... 3 
  Chapter 2 – Anatomy of the tracking board........................................................................................................ 4 
  Chapter 3 – Tracking board columns – what does it all mean? .......................................................................... 5 
  Chapter 4 – Default View vs. Logging Into the Tracking Board........................................................................ 6 
  Chapter 5 – Tracking Board Refresh .................................................................................................................. 7 
  Chapter 6 – Triage procedures with the tracking board ...................................................................................... 8 
  Chapter 7 – Assign a waiting room patient to a bed ......................................................................................... 10 
  Chapter 8 – Assign yourself to a patient ........................................................................................................... 10 
  Chapter 9 – Change Location of the patient ..................................................................................................... 11 
  Chapter 10 – Change the STATUS / NEEDS indicator for the patient ............................................................ 11 
  Chapter 11 – Disposition a patient – Discharge or Consult .............................................................................. 11 
  Chapter 12 – Don’t forget to Logoff or EXIT the tracking board .................................................................... 12 




University of Toledo Medical Center – Horizon Emergency Care Nursing Training Manual                                                                   2
Chapter 1 – Logging In: Accessing the Tracking Board through PC View
                 The Tracking Board is accessed by double clicking the desktop icon named “ED
                 Tracking Board.”




QUICKVIEW: To launch the tracking board you don’t need to log in using your UserID and
Password. You can simply click the QUICKVIEW button and the tracking board will display. At this
level. You are not really logged in. The tracking board is open at the DEFAULT USER level.




                             Tracking Board and HEC
                               Ten Commandments


1.   Thou shalt not share passwords.
2.   Thou shalt log off tracking board every time you walk away from computer.
3.   Thou shalt confirm correct patient record is open before documenting.
4.   Thou shalt be patient with the super users.

(Yes there are only 4 for now. 6 more will be coming when we go live on HEC Documentation)




University of Toledo Medical Center – Horizon Emergency Care Nursing Training Manual               3
Chapter 2 – Anatomy of the tracking board
                                    1
                                                                2


                                                            3


                                                                                          4




                                                                                                5




The tracking board can be configured for different views by workstation its running on. The example shown is
the main tracking board screen. Different configurations can have different buttons, columns, sort order, etc.
The tracking board can show Main ED, Waiting Room or Both areas.

   1) Menu Bar: The menu bar shows drop down menus for the various functions of the tracking
      board. Any item that is grayed out on the menu bar you either don’t have security for, or is
      patient centric and you have to click on a patient row first to un-gray it and make it choose-
      able.

   2) Tool Bar: The tool bar has the most frequent items from the menu bar as quick click buttons
      for convenience. These change based on the role of who is logged in

   3) Sort Filters: These filters let you filter the patients that are viewed on the tracking board. For
      example, you can search by bed, length of stay, triage level, assignment of MD/DO or RN, etc.

   4) Main ED Patients: Shows the patients who are in the emergency department in a standard
      bed or in the hall in an overflow bed.




University of Toledo Medical Center – Horizon Emergency Care Nursing Training Manual                             4
   5) Waiting Room Patients: Shows patients that have been registered as either a full registration
      or quickreg and have either been triaged or waiting for triage.

Chapter 3 – Tracking board columns – what does it all mean?
BED: displays the bed number, keep in mind that the bed can seat multiple patients (i.e. ‘Jones, family of three
your table is ready’) – we can create beds within beds so that multiple kids with the same complaint in a family
can all seat on a stretcher and be seen en masse’ by the clinician. The BED column will turn green to signify
the patient is ready to be discharged.

LOS: Reflects the patient’s length of stay. This is a counter that begins at the time the patient was registered. It
helps to sort patients based on their presentation to the ED after they are sorted based on triage level.

ALERT: This column displays various staff alerts about the patient such as fall risk, psych patient, name alert
(when two or more patients in the ED have similar sounding names).

PATIENT: This should show patient name in secure areas of the ED where the public cannot easily see. In
patient rooms and public areas or on mobile devices this may be abbreviated by the tracking board
configuration of that device to only show the first and last name initials.
    • COLORS: Colors on the name column indicate the triage level:
           o Cyan:             1 – Critical                               o Green:       4 – Non-Urgent
           o Red:              2 – Urgent                                 o Magenta:     5 – Minor
           o Yellow:           3 – Emergent

AGE: The age of the patient

MD/DO / EDRN: Shows the Emergency Department Physician or Nurse that is assigned to the patient.

LOCATION: Shows the current location of the patient if not in the emergency department. This is used to
communicate that the patient has gone to Xray, CT, Dental Clinic, is waiting in the waiting room, etc.

RESULTS: This gives the status of lab results on a patient. Y is they have results, * indicates a care provider
of the same role as you has not seen them, and ! indicates there is a panic or abnormal value.

LAB #: Indicates how many orders were placed and how many results have been received. (i.e. 5/2 indicates
that five orders were placed but only two out of the five have been resulted).

RN2Do / Sec2Do / Tec2Do: Alerts the various care providers that orders have been placed that need to be
acted on, are in progress or are done.

NEEDS / STATUS: indicates various flags and warnings that should alert all care providers in the department.
For example, we use this to show “waiting for a bed”, “ready for discharge”, “Doc Needed”, etc.

CHIEF COMPLAINT: Shows the major complaint as to why the patient is here today to seek care.

COMMENTS: Additional comments that help to communication situational events or alerts about a patient.



University of Toledo Medical Center – Horizon Emergency Care Nursing Training Manual                              5
Chapter 4 – Default View vs. Logging Into the Tracking Board
Each practitioner will have his/her own unique ID and confidential password that will create an
electronic signature for documentation. When you are doing any documentation it is important to log
in and out of tracking board. Your network / email login is not the same as your Horizon Clinicals
(Tracking Board, Horizon Emergency Care, Care Manager) login.

The ID and password are case sensitive. The password is chosen by the individual and must be
at least five characters in length.

                   KEY POINT: The login User ID and Password are NEVER shared since
                   using these constitutes that practitioner’s legal signature. 




Attending Physicians and Residents are built using their physician number as their userID and a
password of their choice. Medical Students, Nursing staff and other care providers are built using
their first names Initial, their last names initial and the last four digits of their Social Security
number and a password of their choice. i.e. John Smith with a SS# of 292-66-4256 would have a
login ID of JS4256 and a password of his choice.

   If you forget your login credentials, please call the help desk to
                    have it reset at 419-383-2400
When you click QuickView you are signing on to the tracking board as the DEFAULT USER. This
login level essentially gets the tracking board display up but technically it’s a public login which
anyone can use.
    • At this default level you’re not really logged in as an individual and it’s not recording user
        context with each event.
    • The second level login is used when you are going to do something like modifying patient
        specific tracking board info or documenting on a patient. These events date/time stamp and
        name stamp the event with the identifier of who is logged in into the patient record and log
        files.
So for some events, you will want to log in and then log off when done. Each time, returning to the
public login or default level which still displays the tracking board, but with no user context. This way
you assure that nobody is documenting with your credentials.

If you are in the DEFAULT user login – you’re not logged in as a discrete user – you will see on the
top boarder of the tracking board:


The LOGIN button will be
displayed and the USER: name
will be “Default”.



University of Toledo Medical Center – Horizon Emergency Care Nursing Training Manual                        6
When you are logged in
as yourself, the top
boarder will change to
reflect your user name
and you will not see the
LOGIN button, it will change to the CHART button and the button bar itself will have changed
configuration.

Make sure when you leave a tracking board that you have logged into, that you logoff
using the LOGOFF button. Otherwise, it is possible someone may chart using your
electronic signature by accident! It is YOUR responsibility to logoff when you are
done.

                         KEY POINT: Always LOG IN when you are documenting or doing patient
                         specific events and then LOG OFF when done so others don’t document
                         with your credentials – if you leave the tracking board logged in as
                         yourself, your handing someone a blank check! 




Chapter 5 – Tracking Board Refresh
The tracking board is set up to check the database of the McKesson Horizon Clinical Systems periodically.
There is a count timer at the top of the board. The refresh period is
60 seconds. The countdown timer reflects the time since the last
refresh. To force a refresh and re-read of the database and update all
the elements on the tracking board, click the REFRESH button.




University of Toledo Medical Center – Horizon Emergency Care Nursing Training Manual                        7
Chapter 6 – Triage procedures with the tracking board                                                  The Brady kids
                                                                                                       have already been
                                                                                                       triaged
When a patient is registered by the ED clerks they will show up on the waiting room census.



                                                                                     Next patient to triage
                                                                                     Double click their name

Patients who do not have a TRIAGE category assigned have not been fully triaged yet. Patients who do, are
waiting to be brought back to the department unless otherwise noted in the comment field. The PAGER column
will display the pager number they were issued to call them from the waiting room to the department. To do so,
dial from any phone X6969 and enter the pager number and then any digits for your return number i.e. 9999 and
the pager will go off and you can meet them at the ED entrance.


                    KEY POINT: You should look at the Length of Stay (LOS) to determine
                    who the next person to be seen for triage should be.
                     

When you bring back the patient to triage you will be using the MODIFY screen to add their triage level and
other data points. In this scenario, you must triage Sam Franklyn (Alice from the Brady Bunch’s boyfriend the
butcher). Sam has cut his hand on a meat slicer. When you double click on the patients name you get the
MODIFY form.

The Modify form has some boxes that were filled in by the Admission / Registration process and you cannot
edit. The rest of the form is fields you may need to complete or change through various times of the patients
encounter. To get to the Modify form either double click on the patient name or click the patient row and click
the MODIFY button. The following will detail the TRIAGE PROCESS steps you should complete.

1) CHIEF & SECONDARY COMPLAINT: Document the chief complaint as to why the patient is here.
Prior to the documentation go live, fill out at least a chief complaint which will show on the tracking board. A
secondary complaint can be filled in as necessary. When we go live on documentation, these will be filled in
from the Documentation Module from the choice of a medical problem.
2) TRIAGE LEVEL: Choose the level appropriate for the patient condition at the time you evaluation them.
If re-assessment is necessary enter the Modify form again and, change the level to reflect the patient’s
condition.
Triage levels are based on the ESI 5 Level Triage System
     • 1 – Critical                                                • 4 – Non-Urgent
     • 2 – Urgent                                                  • 5 – Minor
     • 3 – Emergent
(Refer to the Unit Specific Department Guide for the meanings and how to triage based ESI Level 5)
3) COMMENTS: Make any comments you need to in the Comment Box.
4) ARRIVAL TIME: This is filled in based on the Admission information from the McKesson STAR
Registration system but can be adjusted manually if you feel it should be.
5) MOA: Enter the method of arrival which is used for statistics


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                                    1



                                        2                       5                   6                       7


                                                                                                        8



     4
                                                                           3

                                            9                                  10                     11




6) PAGER NUMBER: The number assigned to the patient to call them back to the Emergency Department
7) (RE)ASSESSED: The column on the waiting room tracking board will turn PINK to alert the triage nurse
that the patient’s length of stay has gone beyond 30 minutes since last assessment and the triage nurse should go
to the waiting room and re-assess the patient and then when complete, change the status of this field to
ASSESSED or RE-ASSESSED.
8) ASSIGN BED: Used to put the patient in a bed (see chapter 8)
9) LOCATION: Where the patient current is (see chapter 10)
10) STATUS / NEEDS: This is used to indicate various status changes of the patient (see chapter 11)
11) ALERTS: Allows you to indicate various issues that all staff should be
alerted to. If you have more than one alert, choose MULTI and then put in
comment the list of multiple alerts.




University of Toledo Medical Center – Horizon Emergency Care Nursing Training Manual                            9
Chapter 7 – Assign a waiting room patient to a bed
To assign a patient from the waiting room to a bed, double click on the patient name and the MODIFY form
will pop up. Choose
the “ASSIGN BED”                                                                             Assign a patient to a bed
                                                                                             Double click their name
button and you will
get the bed list
showing which beds
are available (note that dirty and blocked beds will not show on this screen, you will have to refer
to the main tracking board display for these details).

Click on the BED FILTER if you wish to filter off the dirty or blocked beds by choosing one of
the filter choices. You will probably have to check the BLOCKED BEDS filter quickly if the ED
is expecting ambulance patients in so that you know which ones have already been blocked for
those patients.

Click on the BED number you wish to place the patient in and click OK.



Chapter 8 – Assign yourself to a patient
After you have assigned the patient to a bed you probably
would also want to assign yourself as the primary nurse for the
patient. To do so, click on the tracking board column listed as
EDRN.

At the Default User level you will get the ASSIGN STAFF TO
PATIENT form pop up. You will need to click on the STAFF
Group you wish to assign (RN, MD, RES, etc) and then on the
Available Staff Name and then click the ASSIGN button to
make the assignment.

If logged in you will see a message asking if you want to be
assigned to that patient. If you see the message “The current
Staff is not ON-DUTY” then you should exit that form and click on the ON DUTY button and then try again….
You forgot to set yourself ON DUTY at the beginning of the shift.

After a staff assignment is made, either by the ASSIGN STAFF TO PATIENT form or by
clicking on the column, your name will show up in the correct provider column on the
tracking board.




University of Toledo Medical Center – Horizon Emergency Care Nursing Training Manual                                10
Chapter 9 – Change Location of the patient
The LOCATION column on the Tracking Board helps to show where the patient is in the
care process. If they leave the department to go to an ancillary department such as
Radiology, Ultrasound, CT, MRI, or if we need the room and are waiting for lab results
and the patient is stable to go to the Café or the Waiting Room, we can set the location
column on the tracking board to alert staff. Click on the LOCATION column or choose
the LOCATION toolbar item and change the LOCATION FORM choice to reflect the
appropriate current location of the patient. After the patient returns to the department, the
tracking board should be set to r/t ED to indicate that they have gone and returned.


Chapter 10 – Change the STATUS / NEEDS indicator for the patient
                                            The MODIFY FORM has a drop down that indicates various status
                                            for the patient or needs. This can include that the patient is ‘Ready
                                            for Discharge’, ‘ Waiting for a bed’, ‘ Needs a bedpan’, etc.

                                            The Tracking board will be configured to show colors in various
                                            columns based on the STATS / NEEDS column or based on the
                                            configuration of the tracking board on that device. Be sure to check
                                            with the ED Charge Nurse if there are new status/needs items you are
                                            not sure of how to use.


Chapter 11 – Disposition a patient – Discharge or Consult




1) When a patient is ready for discharge, they are “Dispositioned” from the tracking board. This is done with
the DISPO button on the toolbar. From the DISPOSITION form the MD will choose three things.
    • Enter the disposition time the MD made a decision. Click on the down arrow in each field and the
       current date and time will be filled in.


University of Toledo Medical Center – Horizon Emergency Care Nursing Training Manual                            11
    • If the patient is to be referred to a consult with a hospital service for admission, use the dropdown
       CONSULT TO and choose or type in a service.
    • If the patient is to be discharged home or from the ED, enter information into the D/C instructions or
       note “SEE CHART” so the nurse knows what to put on the Discharge Instructions.




These events are time stamped in the tracking board logs for generation
of statistics.

2) When the MD has filled in anything in the Decision to Dispo field but
there is nothing in the CONSULT service drop down, the BED column
will turn green indicating to the nurse that the patient can be discharged.

                  KEY POINT: The MD SHOULD NOT click on the DISPOSITION drop down as                           3)
                  this will be done when the nurse actually sends the patient from the department out the
                  door. Putting something in the DISPOSITION drop down and clicking OK
                  REMOVES the patient from the tracking board !!!
                   

The Nurse should then go into the DISPOSITION FORM and choose a disposition reason to remove the patient
from the tracking board. Immediately upon this event, the tracking board will show the room as UNCLEAN
and after someone has cleaned the room they can click on the room row on the tracking board
                           and go to the BED menubar dropdown and mark the bed as clean
                           or click on the CLEAN button on the tracking board.




Chapter 12 – Don’t forget to Logoff or EXIT the tracking board
                           When you leave a device in the patient room or a mobile / hall device, click on the
                           EXIT button to fully close the tracking board. Clicking the LOGOFF takes you out of
                           the second level log in to the tracking board and returns the tracking board to the
                           DEFAULT user level waiting for the next person. The difference between using the
                           two should be dictated by where the location of the workstation.
   •   If it’s in a public place displaying other patient names, then you should EXIT.
   •   If it’s within the nursing station or in a private office location then LOGOFF and return to the tracking
       board as the DEFAULT user leaving the patient display up for the next user.




University of Toledo Medical Center – Horizon Emergency Care Nursing Training Manual                           12
                  KEY POINT: You, and ONLY you are responsible for your login. You
                  WILL be held accountable for leaving yourself logged in to a workstation
                  and exposing patient information where you are not authorized to do so.
                  Certain workstations (such as the attending desk while they are on duty)
                  are allowed to stay logged in as that attending with the expectation that
                  nobody else should touch their workstation. You should NEVER walk
                  away from a workstation in a hallway or patient room without exiting the
                  tracking board.
                   




University of Toledo Medical Center – Horizon Emergency Care Nursing Training Manual          13
    UTMC Tracking Board Physician Quick Guide:
1 – Logging In: Accessing the Tracking Board through PC View
                 The Tracking Board is accessed by double clicking the desktop icon named “ED
                 Tracking Board” and then clicking the QUICKVIEW button. To display the tracking
                                        board you don’t need to log in using your UserID and
                                        Password.

                                                                                          B. Click on the row for
                                                                                          EDMD on the left and
2 – Assign yourself to a patient                                                          your name on the right




                               A. Click on the
                               column for MD/DO on
                               the row of the patient
                               you want
                                                                                            C. Click the Assign
                                                                                            button and click OK
3 – EDMD & EDRN Staff Alerts
To communicate between nurse and physician that a patient is in the room and ready to be seen by the MD, the
nurse will turn on the EDMD staff alert. This turns the physician column on the patient row GREEN. When
you have acknowledged this, you can turn the alert off using the MD ALRT OFF button or use the function off
the PATIENT dropdown menu “EDMD Alert Off”.

To notify the nurse that you have Lab, Medication or other orders that need attention. Turn on the EDRN
ALERT. This will highlight the EDRN column on the tracking board for that patient YELLOW.

4 – Disposition a patient
To disposition a patient to either a consult service for an admit
or to send home, click once on the patient row and then click
the DISPO button.
    • To disposition to a consult service, enter a time in the
        “Decision to Dispo” area and enter the “Consult To”
        service in the dropdown
    • To disposition a patient home, just enter the “Decision
        to Dispo” time and click OK leaving everything else
        blank. The Room number will now turn GREEN indicating to the nurse that you have written D/C
        instructions.



University of Toledo Medical Center – Horizon Emergency Care Nursing Training Manual                           1
        Anatomy of the tracking board:
                         1
                                             2


                                                            3
                                                                                          4




                                                                                                5




The tracking board can be configured for different views by workstation its running on. The example shown is
the main tracking board screen. Different configurations can have different buttons, columns, sort order, etc.
The tracking board can show Main ED, Waiting Room or Both areas.

   1) Menu Bar: The menu bar shows drop down menus for the various functions of the tracking
      board. Any item that is grayed out on the menu bar you either don’t have security for, or is
      patient centric and you have to click on a patient row first to un-gray it and make it choose-
      able.

   2) Tool Bar: The tool bar has the most frequent items from the menu bar as quick click buttons
      for convenience. These change based on the role of who is logged in

   3) Sort Filters: These filters let you filter the patients that are viewed on the tracking board. For
      example, you can search by bed, length of stay, triage level, assignment of MD/DO or RN, etc.

   4) Main ED Patients: Shows the patients who are in the emergency department in a standard
      bed or in the hall in an overflow bed.

   5) Waiting Room Patients: Shows patients that have been registered as either a full registration
      or quickreg and have either been triaged or waiting for triage.


University of Toledo Medical Center – Horizon Emergency Care Nursing Training Manual                             2
                  Tracking board columns:
BED: displays the bed number, keep in mind that the bed can seat multiple patients (i.e. ‘Jones, family of three
your table is ready’) – we can create beds within beds so that multiple kids with the same complaint in a family
can all seat on a stretcher and be seen en masse’ by the clinician. The BED column will turn green to signify
the patient is ready to be discharged. If the bed number turns GREEN, it indicates the patient is ready for
Discharge

LOS: Reflects the patient’s length of stay. This is a counter that begins at the time the patient was registered. It
helps to sort patients based on their presentation to the ED after they are sorted based on triage level.

ALERT: This column displays various staff alerts about the patient such as fall risk, psych patient, name alert
(when two or more patients in the ED have similar sounding names).

PATIENT: This should show patient name in secure areas of the ED where the public cannot easily see. In
patient rooms and public areas or on mobile devices this may be abbreviated by the tracking board
configuration of that device to only show the first and last name initials.
    • COLORS: Colors on the name column indicate the triage level:
           o Cyan: 1 – Critical                                           o Green: 4 – Non-Urgent
           o Red:       2 – Urgent                                        o Magenta: 5 – Minor
           o Yellow: 3 – Emergent

MD/DO / EDRN: Shows the Emergency Department Physician or Nurse that is assigned to the patient. If the
physician column is GREEN, it indicates the patient is in the room, changed and ready for the physician to see.
If the nurse column is YELLOW it indicates that the physician has ordered something that the nurse needs to
address by looking at the physician chart/

LOCATION: Shows the current location of the patient if not in the emergency department. This is used to
communicate that the patient has gone to Xray, CT, Dental Clinic, is waiting in the waiting room, etc.

RESULTS: This gives the status of lab results on a patient. Y is they have results, * indicates a care provider
of the same role as you has not seen them, and ! indicates there is a panic or abnormal value.

LAB #: Indicates how many orders were placed and how many results have been received. (i.e. 5/2 indicates
that five orders were placed but only two out of the five have been resulted).

NEEDS / STATUS: indicates various flags and warnings that should alert all care providers in the department.
For example, we use this to show “waiting for a bed”, “ready for discharge”, “Doc Needed”, etc.

CHIEF COMPLAINT: Shows the major complaint as to why the patient is here today to seek care.

COMMENTS: Additional comments that help to communication situational events or alerts about a patient.




University of Toledo Medical Center – Horizon Emergency Care Nursing Training Manual                              3
 UNIVERSITY OF TOLEDO MEDICAL CENTER
       HORIZON EMERGENCY CARE
      PHYSICIAN TRAINING MANUAL




                         October 2008




HEC MD Training Manual                  1
                                                           Table of Contents
  1 – MD Homepage .............................................................................................................................................. 3 
     Accessing the Tracking Board through PC View ........................................................................................... 3 
     Accessing HEC from the Tracking Board ...................................................................................................... 3 
     Components of the MD Homepage ................................................................................................................ 4 
     Closing the Chart ............................................................................................................................................ 7 
  2 – HEC Screen Behaviors ................................................................................................................................. 8 
     Scrolling Lists ................................................................................................................................................. 8 
     Charting Paths ................................................................................................................................................. 9 
     HEC Graphics ............................................................................................................................................... 11 
  3 – Adding a Medical Problem ......................................................................................................................... 12 
     Medical/Surgical Problem ............................................................................................................................ 12 
  4. Documenting HPI, PMH, SH, FH and Physical Exam ................................................................................. 14 
     HPI – The episode of documentation starts here .......................................................................................... 14 
     Vital Signs..................................................................................................................................................... 19 
  Chapter 5 – Patient Orders ................................................................................................................................ 21 
     Order Entry ................................................................................................................................................... 21 
     Searching Orders ........................................................................................................................................... 22 
     Selecting Orders ............................................................................................................................................ 23 
     Order Protocols ............................................................................................................................................. 25 
     Cancel/Modify an Order ............................................................................................................................... 27 
  6. Patient Update and Transfer of Care:............................................................................................................ 28 
  7. Free Text Note: ............................................................................................................................................. 29 
  8. Chart Viewer Tab:......................................................................................................................................... 29 
     ABG Studies ................................................................................................................................................. 30 
     Medical Imaging ........................................................................................................................................... 31 
     EKG .............................................................................................................................................................. 32 
  9. Add Diagnosis ............................................................................................................................................... 33 
  10. Procedures ................................................................................................................................................... 33 
  11. Review ........................................................................................................................................................ 34 
  12. Consultations............................................................................................................................................... 34 
  13. Disposition .................................................................................................................................................. 35 
     Discharge Instructions: ................................................................................................................................. 37 
     Completing the Disposition .......................................................................................................................... 38 
  14. Printing........................................................................................................................................................ 38 
  15. Chart Finder ................................................................................................................................................ 39 
     Choose a List or Search ................................................................................................................................ 41 
     Searching by Patient or Provider .................................................................................................................. 42 
     Choose an Action .......................................................................................................................................... 43 
     Addendum Mode .......................................................................................................................................... 44 
  HEC Ten Beginner Mistakes (it’s OK) ............................................................................................................. 45 
  HEC Seven Stupid Things That Can’t Be Changed and Could Feel Sticky ..................................................... 45 
  HEC Ten Commandments ................................................................................................................................ 45 




HEC MD Training Manual                                                                                                                                                  2
1 – MD Homepage

               Accessing the Tracking Board through PC View

               The Tracking Board is accessed by double clicking the desktop icon named “ED
               Tracking Board.” You can use the QuickView button to open the tracking board
               without logging in, but for charting each practitioner will have his/her own unique
               ID and confidential password that will create an electronic signature
               for documentation.




The ID and password are case sensitive. The password is chosen by the individual and must be
at least six characters in length. The login User ID and Password are NEVER shared since
using these constitutes that practitioner’s legal signature.


Accessing HEC from the Tracking Board
Logging into PCView will launch the ED Tracking Board. Launching HEC requires 3 steps.

1. On the Tracking Board, click the Login button. Enter your ID and password.




HEC MD Training Manual                                                                               3
2. Select a patient on the tracking board and highlight them by clicking once on their name

3. Click the CHART button on the Tracking Board toolbar.




Components of the MD Homepage
After launching HEC, the patient’s chart is displayed in the main charting screen called the Home
Page. The Home Page serves as the launch pad for all documentation and as the primary online
review of the patient chart.




HEC MD Training Manual                                                                              4
Components (Numbers correspond to highlighted numbers above)

1. Menu Items The menu items allow the user to access various options. Some
of the most commonly used items are:

              Menu    Element          Description
                                       Returns you to the tracking board without
                      Return to
                                       completely closing HEC. This is the preferred
              File    Tracking
                                       way to go back to the Tracking Board to select
                      Board
                                       another patient to chart on.
              View    Refresh          Updates data in the documentation window.

                                       Allows you to set a preferred default view of the
                                       patient chart and the font size. Preferences are
              Tools   Preferences
                                       saved by your login so any changes you make
                                       will display the next time you login.
              Help    Contents         This gives access to the HEC online help files.

2. Patient Banner Patient information is displayed at the top of the Home Page. This area is called
the “patient banner”. It displays the patient’s name and demographic information.
It also displays important allergy information.

Allergies Allergy information is displayed in the patient banner.
   • You can hover over the allergy button to quickly display allergies.
   • You can click on the allergy button to review- allergies.
   • Access Med HX located on the tracking board to chart allergies (preferred).
         o Note: During downtime, chart allergies in HEC.

                                    The button is red if allergens have been documented.

                                    The
                                    button is yellow if allergens have not been documented
                                    The button is gray if patient has “No Known Allergies”


3. Vital Signs The patient’s most recent vital signs display in this area.
If you hover over a vital sign, trended results and methods taken are displayed for all vitals signs
.
             Indicates the value is borderline high or low of normal


             Indicates the value is outside the normal range.




HEC MD Training Manual                                                                                 5
4. Navigational Tabs These tabs allow the user to navigate to different windows

   TAB                Description
   MD Charting        Displays the charting Home Page
   Manage Orders      Displays the orders’ management window used to enter orders,
                      acknowledge, document orders tasks, modify, cancel and complete
                      orders.
   Enter Orders       Displays the Order Entry window used to enter orders
   Chart Viewer       Displays the patient’s chart in a Chart Viewer browser window.
   Add                Displays the window to document the Chief Complaint
   Medical Problem
   Enter Orders       Displays the Order Entry Window (Does the same thing as the
                      Enter Orders Tab above)
   Print/Fax          Displays the window to print or fax patient reports.


5. Documentation Links The links in the left pane of the Home Page take the user to
various charting windows. These charting windows are described below.

     TAB                 DESCRIPTION
     HPI                 Document patient’s history of present illness.
     PMH – FH- SH        Document patient’s past medical history, family history and social
                         history.
     Physical            Document patient’s Physical Exam

     Vitals Summary      Review vital signs history or add a new vitals sign


     Labs                Review Lab Results

     ABG                 Enter Arterial Blood Gas results and interpret them
     XRay                Interpret Radiology Studies
     EKG - Monitor       Interpret EKG tracings or monitor readings

     Patient Update      Document the patient’s current status and changes in patient
     Free Text Note      Add a note in free text
     Consult Note        Document consultations with other practitioners and oversee mid level
                         providers
     Add Diagnosis       Add additional diagnosis
     NIH Stroke          Document an NIH stroke scale
     Scale
     Procedures          Document procedures done for the patient
     Prescriptions       Write Prescriptions
     Review              Review the chart and select a Co-signing MD for Mid Level providers
     Disposition         Disposition the patient – Discharge or Admit




HEC MD Training Manual                                                                           6
6. Charted Documentation Window Information that has been charted on the
patient appears under the applicable heading.

      • Charting done by yourself appears in Blue font and is underlined.
      • You can click on your charting to modify or delete
      • Charting done by another clinician appears in normal black text.
      •When you move the cursor over another person’s charting, the name of the clinician with the
      date and time appears.


Closing the Chart
The appropriate way to close a chart depends on whether you plan to chart on another patient or
exit HEC completely.

1. IF you want to chart on another patient:
       From the menu list select File, Return to Tracking Board. This returns the user
       to the tracking board while keeping the HEC application running, and allows you to launch a
       new patient chart much faster.




2. IF you want to exit the HEC application:
       Select the Close Button from the upper right corner of the HEC home page.




HEC MD Training Manual                                                                               7
2 – HEC Screen Behaviors

Scrolling Lists
There are many places within the application where a user will be presented with a scrolling list.
        •Scrolling lists have a search bar at the top of the page that will bring the user to the
desired area on the list. (for example, typing a T in the search box will bring the user to the T section
of the list. Scrolling lists are typically alphabetical.)
       •To make a selection on a scrolling list, the user must DOUBLE CLICK on
that selection. This moves the selection from the left column into the right column indicating it has
been selected. To deselect an option, simply double click it in the right column.




Setting a Time Stamp
Due to the fast paced environment in an emergency department, documenting time is important.
There are many time stamps presented throughout the application. The time displayed will default to
the current time. Condell Medical Center recommends point of care charting, but if necessary, the
user can change the time.
To change the time:
   • Use the up and down arrows to change the hours
       or minutes
   • Highlight the number to be changed and type a
       new number


HEC MD Training Manual                                                                                  8
When the time is appropriately set, select USE THIS TIME to accept the time and begin your
documentation.

Note: The application will allow the user to change the time into the future-DO NOT do this, it causes
a error in the application and your charting will reflect yesterdays date


Charting Paths
Much of the HEC application is built on “charting paths,” which present additional charting
screens based on your documentation. A common charting screen presented in HEC is shown
below.




When you are charting in HEC, there are some key things to remember. These include:
     • Only chart on the information that is necessary and relevant to the patient’s condition.
     • Red text indicates a required question. The user will be prompted to address the question if
     they select NEXT before charting on each item with red text.
     •You do not need to answer any questions on a screen to select next and continue to
     the next charting screen.
     •Typically, a user will want to select next to advance on a charting path and to return to
     the home page.




HEC MD Training Manual                                                                                9
The bottom of each charting screen gives the user options as to how to proceed.




      BACK                Takes the user back to the previous charting screen.
      CANCEL              Cancels ALL charting that has taken place at that time since leaving
                          the home page. USE CAUTION
      NEXT                Advances the user on a charting path (preferred).

An example of another charting screen that is common in the HEC application is shown below




      •This type of screen allows the user to select and deselect their charting
      options by clicking on the black text.

      • Each choice you select turns yellow, indicating that the selection is made, and the sentence
      that is added to the patient chart appears below that option in bold text.




HEC MD Training Manual                                                                             10
HEC Graphics
There are many graphics in HEC. An example is shown below.


                                                             Graphics typically
   The user
                                                             are gender and
   can hover
                                                             age specific.
   their cursor over a
   graphic to locate
   a hot spot.



   Clicking on the
   hot spot opens a
   charting path.




HEC MD Training Manual                                                            11
3 – Adding a Medical Problem
Medical/Surgical Problem
The Add Medical Problem button provides access to add a chief complaint for a patient. The chief
complaint drives the charting flow, and it is required prior to documenting in HEC. When
choosing a medical problem, look for a global chief complaint that will include multiple problems.
Typically, users should enter just one chief complaint.

Selecting the Add Medical Problem button from the home page launches the following screen.




There are two ways to enter a patient’s chief complaint:


Medical/Surgical Button

The most common method is to
select the Medical/Surgical button.
This will generate a scrolling list
of chief complaints from which
you can select.




HEC MD Training Manual                                                                               12
Soft Tissue Problems

For soft tissue and local injuries, use the body image graphic by clicking on the affected
area to select the chief complaint.




After clicking on the body image, “What is the nature of this problem “ dialogue box is displayed.
Additional dialogue boxes are presented based on your selections, which allow you to describe the
soft tissue problem.

Pediatric Patients
For pediatric patients, a General Pediatrics button is displayed right below the Medical/Surgical
button.

Note: The pediatric patient age limit is 12 years old. This is set by McKesson.




HEC MD Training Manual                                                                               13
4. Documenting HPI, PMH, SH, FH and Physical Exam

HPI – The episode of documentation starts here
The HPI option brings the user to the History and Physical Exam screen. Clicking on HPI marks the start
time of the encounter in HEC.
 This is where the user will see how the chief complaint drives the history documentation. In the example
shown below, the chief complaint of “Abdominal Pain” presents the Quick Chart-GI Problems and ABD.
PAIN-N/V-Diarrhea-HERNIS-ETC options. Clicking on either of these options allows the user to document
the subjective and objective data surrounding this chief complaint.




NOTE: If a chief complaint has not been selected for this patient encounter, the user will be presented
with the chief complaint graphic first. This really shouldn’t happen for the physician as the nurse via the
triage functions has already generated a chief complaint.




HEC MD Training Manual                                                                                        14
Selecting the chief complaint (s) drives the application to present various structured histories and “Quick
Charts.”
Preferred “Quick Charts” may include:
           • UTI                                                         • Sepsis
           • URI                                                         • Kidney stone
           • Sickle Cell                                                 • Toothache
           • Back Pain                                                   • Chest Pain




Check the buttons and/or boxes regarding nursing notes and record review. “Discrepancy noted” will open a
text box to describe any discrepancy. Checking the “nursing note reviewed…” will assist with coding as the
coder may use nursing documentation to justify coding.

Structured history and charting pathways: These may appear based upon primary complaint as entered by
the nurse in triage. Using the PMH – PH –SH – ROS button will allow you to access the Past Medical History,
Family History, Social History and Review of Systems.




HEC MD Training Manual                                                                                        15
The Quick Click Exam option is found only on the History and Physical Exam screen. This exam allows the
user to document quickly pertinent positives and negatives of their head-to-toe exam.
This is an excellent means of easily and quickly documenting physical findings for most presenting complaints.




HEC MD Training Manual                                                                                      16
The Soft Tissue Exam option presents the user with several options for documenting a soft tissue exam. This
area is generally used to document traumas or injuries. This option can also be found on the Physical Exam
screen.




The PMH-SH-FH option allows the user to document past medical/surgical/social history, as well as a review
of systems.




HEC MD Training Manual                                                                                    17
The Physical option brings the user to the General Physical Exam screen. NOTE: There are several other
exam options near the top of this screen.




Selecting NL on the General Physical Exam screen brings default
normal text return into the medical record. Selecting ABN will bring
the clinician to follow-up screens that allow both normal and abnormal
charting options. Selecting My Defaults and clicking on one of the
exam types checks NL on some of the systems.
My STANDARD Normal Exam returns the following normal values:
General Presentation
ENT Exam
Eye Exam
Pulmonary Exam
Cardiac Exam
Abdominal Exam
Skin Exam
Psychiatric Exam (Neuro-Psychiatric)                                    My STROKE Normal Exam returns the following normal values:
                                                                        General Presentation
My EXTENDED Normal Exam returns the following normal values:            ENT Exam
General Presentation                                                    Eye Exam
ENT Exam                                                                Pulmonary Exam
Eye Exam                                                                Cardiac Exam
Pulmonary Exam                                                          Abdominal Exam
Cardiac Exam                                                            Neuro Exam
Abdominal Exam                                                          Psychiatric Exam (Neuro-Psychiatric)
Neuro Exam
Psychiatric Exam (Neuro-Psychiatric)                                    My TRAUMA Normal Exam returns the following normal values:
SKIN- you must select the values, it does not return a default normal   General Presentation
statement                                                               ENT Exam
                                                                        Eye Exam
My CARDIAC Normal Exam returns the following normal values:             Pulmonary Exam
General Presentation                                                    Cardiac Exam
ENT Exam                                                                Abdominal Exam
Eye Exam                                                                Musculoskeletal Exam
Pulmonary Exam                                                          Psychiatric Exam (Neuro-Psychiatric)
Cardiac Exam
Abdominal Exam
Psychiatric Exam (Neuro-Psychiatric)




HEC MD Training Manual                                                                                                               18
Vital Signs
The Vital Signs option allows the user a view of all vital signs that have been entered on one screen.
Vital signs can be added, modified or deleted from this screen.




By selecting ADD VITAL SIGNS in the upper right hand corner, the user is presented a screen to
enter vital signs.




HEC MD Training Manual                                                                               19
Vitals are entered in the large boxes below the vital name. Many vitals also offer check boxes
that can be clicked to launch follow up screens to further describe the measurement. The user
can click anywhere on the pain scale to enter the patient’s pain level.

Additional Vital Signs
You can chart Orthostatic VS Set, Glasgow Coma Score and Visual Acuity in this section by checking
the boxes. Additional screens will prompt you for charting.




HEC MD Training Manual                                                                           20
Chapter 5 – Patient Orders

The HEC orders module is made up of two primary screens, the order entry screen and the order
management screen.

Note: HOM will no longer be used as the Order Management System. ED staff will not have access
to HOM.

Order Entry
To access the orders entry screen, select the Enter Orders button or tab from the Homepage.




The Enter Orders screen has four main columns of information:

HEC MD Training Manual                                                                           21
Entered orders This column displays orders that have already been entered for this patient.

Select orders This column displays a list of orders that may be selected. The list can be displayed
in various groups or Protocols based on your search or it can list all orders alphabetically.

Orders to be entered This column displays orders that have been selected by the user but not
yet placed.

Order Details & Warnings This column displays the order details for the order highlighted in the
orders to be entered. The details may be edited in the column prior to being placed. Warnings are
generated by the system on things such as allergy checking. A    indicates there is a prompt or
warning that needs to be addressed before the order can be placed.

Note: When ordering under order detail the medication administration guidelines will display

Searching Orders
There are several different approaches to searching for orders that you would like to place on a
patient.




Search All Orders Clinicians may “Search All Orders” by entering a few letters of their choice in the
search tool near the top of this tab. Entries here will search all orders in HEC and will return any order
with that combination of letters in it. Any order that doesnt display under Select Orders, then search
all orders. This is the main database where all orders reside, including alias names of orders. Alias


HEC MD Training Manual                                                                                 22
names of orders is when an order has another name i.e. CBC also can be searched as Complete
Blood Count. Using this search takes additional time since it’s searching the entire database.
Order Groups Orders have been grouped for efficiently placing orders. All orders is the default order
group presented to the clinician. Selecting one of these order groups changes the orders presented
under the “Select Orders” column. Some of these groups of orders have subsets that appear under
the groupings.

Order Filter The order filter helps the clinician to further constrain the list of orders in the
Select Orders list. If you type AL, the list is constrained to only include the orders that start with AL.

All searching supports aliases that have been built for an order. For example, Tylenol entered
into the search box returns all Acetaminophen orders that have Tylenol built as an Alias.

Note: When searching for medications, lower case denotes that the medication is in Pyxis. When
there is upper case, this denotes that the medication order needs to be sent to pharmacy via fax/tube
system.

Selecting Orders
The first time you open Enter Orders tab a prompt displays and you will need to choose the Ordering
Practitioner. Type in the first couple of letters of the last name and the physician name will display.
Highlight the physician and click on OK or you can double click on the name.

Note: This prompt of Ordering Practitioner will only display once, when order entry tab is chosen by
the Nurse. At change of shift for physicians--in order to change the Attending Service the physician
coming on duty is to place the orders if needed and this will change the Attending Service. Nursing
doesn’t have the access or ability to complete this.




HEC MD Training Manual                                                                                       23
In the Select Orders column, the user selects an order by highlighting the order and selecting the Add
to List button, or by simply double clicking the order item.
All selected orders appear under the “Orders to Be Entered” column.




Order details appear in the far right column for the highlighted order in the Orders to be Entered
column. Prompts that are grayed out are locked and cannot be changed. Prompts displayed in white
cells are available to change.


Required Information
    indicates information is required. Enter the required information on the Order Details tab. Data
entry consists of picking a selection from a drop down list (Method of Transport), or typing free text
into a box (Reason for exam, Comments). You should always review the details of orders before
placing them.
Warnings

If warning messages have been generated by the system, a        will be located to the right of the
Warning tab. Clicking on the warning tab displays the warning in the box below. Warnings must be
addressed by selecting a response from the drop down list.




HEC MD Training Manual                                                                                   24
Once the orders have been selected and reviewed, the clinician can click the enter orders option, and
all orders in the “Orders to Be Entered” column will be entered into the ordering system and populate
the “Entered Orders” column on the far left of this screen.


Note: A Prompt will display, Checking Orders, once complete then the user can click on enter orders




Order Protocols
Order protocols will be commonly used to enter orders on a patient. Order protocols are
displayed in the Select Orders box by clicking on the Sets/Protocols button in the order
group’s area. The Protocol set list is alphabetized and you can use the order filter to help find
a specific set.

To display the individual orders in a set, the clinician can double click the name, or highlight the order
and then select the details button. Selecting a Protocol launches the protocol detail box.




HEC MD Training Manual                                                                                  25
To display the individual orders the clinician can double click the name or highlight the order and
select the “Details” button. It launches the protocol detail box.


                                                                  If you double click the Order Set you
                                                                  get an Order Set Details box with all
                                                                  the orders checked. As in the image to
                                                                  the left.

                                                                  If you click on DETAILS button below
                                                                  the list of order sets, you get an Order
                                                                  Set Details box with no order items
                                                                  checked and you can order the
                                                                  individual orders from the pick list
                                                                  that you want




Protocols categorize separate orders into groupings. The groups are collapsible by changing the
minus sign into a plus sign by clicking on it. The check box next to the group name allows the user to
select or deselect all of the orders in that group. The clinician may also “select all” at the top of the
screen to select all orders in the protocol, and then deselect the orders they do not wish to place by
removing the check from the appropriate check box. Alternatively, you may select none at the top of
the screen and then select the orders you wish to place by adding the check to the appropriate
check box.

Once the appropriate orders are checked, the clinician selects the “Add Orders” button at the bottom
of the Protocol Details box. This adds the selected orders to “Orders to Be Entered” column of the
order entry screen.
Any orders that have details or warnings that need to be addressed display the      next to them.
The clinician may review the details of each order and make changes as necessary under the “Order
Detail” column, then select “enter orders” near the bottom of the screen to place these orders.

Note: During a STAR Registration downtime you can only place orders on all patients that have been
registered. For patients that have not been registered but have been quick admitted you will not be able
to place orders until STAR is available. Only Registrars have access to Quick Admit and Merge.




HEC MD Training Manual                                                                                       26
Order Status




The status of orders change with the completion of these orders. Ancillary orders are completed by
the ancillary system, like lab, and that will message to the status column on the “Manage Orders”
screen.
Completed orders fall to the lower part of the list of orders. New orders stay at the top of the list. By
clicking on the word “status” one can resort these orders, as desired.

Cancel/Modify an Order
The modify button on the orders management screen is used to cancel an order, and to view
medication administration guidelines. These guidelines were documented and reviewed by pharmacy.




To cancel an order, clicking on the Cancel Order
button launches a screen that allows you to select a reason the order is being cancelled.




HEC MD Training Manual                                                                                      27
6. Patient Update and Transfer of Care:
Patient Update brings the user to the Update Note screen. This is where the documentation of the
transfer of care and new problems while in the department occurs.




                                                      Documentation of the transfer of care
                                                      will not be automatically communicated
                                                      with the tracking board. The new
                                                      provider must also update the tracking to
                                                      represent themselves as the new provider
                                                      of care.


HEC MD Training Manual                                                                             28
7. Free Text Note:
The Free Text Note option allows the user to choose which heading a free text note will be placed
under.




8. Chart Viewer Tab:
All roles (MD/RN/PA/NP/Tech/UC) have a tab called Chart Viewer.
The Chart Viewer tab allows the clinician to select a view other than their default view to display the
current charted data.




HEC MD Training Manual                                                                                    29
9. Diagnostic Studies:

When selecting the Labs option, if there are labs to be reviewed, the user will be presented a Lab
Results Summary. If no lab results are available, or the labs have already been reviewed, the user
will see the message in the reviewed column. Reviewed labs add to the complexity and decision
making at the CMS audit at disposition. Providers should view labs in HEC rather than EDTB or portal
to ensure documentation of data review.




ABG Studies
Although in our systems, the ABG studies are part of the lab results. The ABG screen allows you to
enter the ABG results for a patient and interpret them within your documentation. You will enter the
PO2, PCO2 and pH and choose the interpretation text from menus.




HEC MD Training Manual                                                                             30
Medical Imaging
Xrays ordered in HEC will appear in this interpretation box. The physician selects the Interpret Button
for the x-ray they wish to document their interpretation on…




There are approx 160 follow up questions for radiology interpretation.




HEC MD Training Manual                                                                              31
EKG
The EKG option allows the user to document their interpretation of an EKG or rhythm strip.




This is the Master EKG Interpretation Work Sheet.
The graphic shown on the left opens a charting path to document specific findings of the EKG waves.




HEC MD Training Manual                                                                           32
9. Add Diagnosis
The Add Diagnosis option presents the user with a scrolling list of diagnoses.
If a diagnosis has not been generated in documentation prior to discharge, the user has the option of
selecting a diagnosis here for the patient encounter. If no diagnosis has been selected, clicking on
“Disposition” will offer the user a list of diagnoses based upon previously entered documentation.




10. Procedures
The Procedures option presents the user with a scrolling list of procedures to document.
Many procedures will already have been documented in earlier workflows.




HEC MD Training Manual                                                                             33
11. Review
Review provides access to chart review, other reviews, and provider assignments. The Provider Assignments
option is used by NP’s, PA’s, DO’s and Residents that need to have a co-signing MD.




12. Consultations
Attending Physician Reviewing a Resident or Medical Student’s Chart




Produces in the chart:
Have reviewed the available ER record. I was present and materially participated in this patient's care
as follows: I reviewed and confirmed with corrections and additions as noted in the record the
Resident/PA/ARNP medical history, physical exam, diagnostic tests, diagnostic test interpretation,
assessment, diagnosis, and discharge plan. I reviewed and directed the Resident/PA/ARNP
Emergency Department patient treatment. I performed procedures as noted in the record.
EMERGENCY DOCTOR MD - Electronic Signature. At this point I agree with the current assessment
done in the Emergency Department. The most likely diagnosis at this point is Chest pain.



HEC MD Training Manual                                                                                      34
13. Disposition
From the Disposition screen, the user can add or change the diagnosis, critical care time,
prescriptions, and discharge instructions. The CMS audit is accessible only when the audit level does
NOT match the recommended level. If a diagnosis has not been documented, the user will first be
presented with a list of possible diagnoses. The last selection on this screen is the diagnosis scrolling
list.




When the physician makes the decision to disposition a patient, they go to the disposition screen within HEC
Documentation Module. From this screen, the physician can view the current E/M audit level for this
encounter. The application will notify the physician what E/M level their documentation currently supports,
and potentially what level this visit could be coded at, based on the diagnosis codes generated during the
documentation of the encounter.




HEC MD Training Manual                                                                                         35
From here, the physician may review a tally sheet of audit criteria, and evaluation screen is
displayed. From this screen the application offers suggestions on areas of documentation needing
more detail to raise the CMS Audit level.




The Disposition screen should be completed in a systematic way, so as not to miss any areas of
documentation.

                                             The default setting for all follow-ups is 3-5 days, but
                                             can be changed by deleting the 3-5 and inserting the
                                             desired text.
                                             Prescriptions can be written from the Home page or
                                             the Disposition Screen. Prescriptions are grouped for
                                             efficiency. The ALL OTHER medications in the bottom
                                             right corner presents a scrolling list of prescriptions.




                              When you are done with your prescriptions, click on the Print Other
                              Reports and choose the Prescription report and print it to the
                              prescription printer. This just saves a step by doing it from the
                              disposition screen.




HEC MD Training Manual                                                                              36
Discharge Instructions:
DO NOT select a discharge instruction from the HEC discharge instructions presented list as UTMC
is using another Discharge Instruction program superior to the instructions in HEC. If you choose
one, it will put the text of the HEC discharge instruction in the patient chart and that text may not
match the text of the instructions we actually give the patient. Choose CLICK HERE TO ENTER
CUSTOM INSTRUCTIONS and fill in the box. Enter any diagnosis you would like an instruction
sheet generated for an then enter any specific instructions you want the discharging nurse to add to
what is given to the patient.




HEC MD Training Manual                                                                              37
Completing the Disposition
   •   Patient Disposition (opens secondary dialog with admit or transfer)
   •   Enter condition at Disposition (required by JCAHO)
   •   Click on “Auto Sign All Orders” and “Sign the Chart” to add your electronic signature. Signing chart
       closes documentation for other MD’s.
   •   Do NOT check “Close Out RN Charting.” As the nurse still has to give discharge instructions,
       complete discharge care and disposition the patient off the tracking board.




14. Printing
The Print/Fax option provides access for the user to print instructions and prescriptions as well as
print or electronically fax the medical record. Ideally, Prescriptions would be printed at the end of the
disposition screen.




HEC MD Training Manual                                                                                        38
15. Chart Finder




NOTE: It is recommended that all users check their unsigned chart cue at the end of each shift, to be
sure all documentation for the day is complete. Once Chart Finder is launched, the user can choose a
list or search, or query all charts with a certain status.




This query searched all charts with the last name of Patient. By highlighting the appropriate chart, the
user can select to launch the chart as shown at the bottom of the screen.
NOTE: This drop down option allows the physician to choose the cosign chart option. Click GO to
launch the chart.



HEC MD Training Manual                                                                               39
When the selected chart is launched from chart finder, if it is a closed/complete chart the chart will be
opened in addendum mode. This is where users can document any care/interventions that happened
after the patient left. The addendum mode charting allows for only free text entries.




You can also use ChartFinder to re-assign or Change the Provider.




HEC MD Training Manual                                                                                40
The top portion of the Chart Finder screen has several options to search for the appropriate charts.




Choose a List or Search




The Choose a List or Search option is used to find unsigned charts. The searching
options for nurses include:

Search: Displays all charts that have been dispositional off the Tracking Board.

All MD Unsigned Charts – Displays all dispositional charts that do not have an MD signature.

My Incomplete RN Charts Displays all dispositional charts that are unsigned and assigned to
the current user.

All Incomplete RN Charts – Displays all dispositional charts that do not have an RN signature.




HEC MD Training Manual                                                                                 41
All Incomplete Charts – No Charting – Displays all charts that do not have the patient’s chief
complaint or vital signs charted.

Searching by Patient or Provider
Chart Finder also allows searching for patient charts by patient information or provider information.




The Status Drop Down can be used in conjunction with Patient or Provider search criteria to constrain
a search. The options under the Status Filter are:

   •   All Charts – Charts dispositional off the Tracking Board, regardless of status.
   •   Final – Charts with MD and RN signoff
   •   MD Final – Charts with MD signoff
   •   Interim – Charts with no MD signoff
   •   Addendum – All – Charts with MD or RN addendum charting
   •   Addendum RN – Charts with RN addendum charting
   •   Addendum – MD – Charts with MD addendum charting

Note: If you want to see all patients in the emergency room-for example-yesterdays patient.
           1. Type in under the start Disposition Date.
           2. Type in under the end Disposition Date.
           3. This will display patients dispositioned during the searched period.




HEC MD Training Manual                                                                                  42
Choose an Action
Search results are displayed in the main body of the chart
finder screen. Highlight the correct patient encounter, and choose an action from the drop-
down list. You can also launch an HEC chart by double clicking the patient encounter.




The “Choose an Action” drop-down box offers the following options:

   •   Launch Selected Charts
   •   Reassign Treating Provider
   •   Reassign Cosigning MD
   •   Reassign Assigned RN
   •   Delete Selected Charts (No Charting Only)

When launching a patient chart, one of the following results occurs:

   •   If the patient’s chart is unsigned, HEC opens normally to allow you to finish the disposition and
       sign-off process.

   •   If the patient’s chart is signed, HEC opens in addendum mode to allow you to review the chart
       and add further information to the chart as an addendum note.




HEC MD Training Manual                                                                                43
Addendum Mode




When the chart launches in addendum mode, you cannot return to the normal charting screens to
enter information. Instead, any information added to a patient chart must be added as an addendum
note. Clicking on the Add Addendum Note button launches a text box where you can enter
information. You can paste text into the box as needed.

Note: Using the Addendum mode is highly discouraged
The below describe when charts will go in an addendum mode

    Addendum Mode

    RN removes from Tracking Board, MD signs chart               No Addendum
    RN removes from Tracking Board and closes chart, MD          RN & MD Addendum
    signs chart
    RN closes chart – patient still on Tracking Board            No Addendum
    RN closes chart, MD signs chart – patient still on           No Addendum
    Tracking Board
    MD signs chart, RN does not close chart – patient still on   No Addendum
    Tracking Board
    RN removes patient from Tracking Board and closes            RN Addendum
    chart




HEC MD Training Manual                                                                          44
                                                   HEC
                                       Ten Beginner Mistakes (it’s OK)



1.Documenting on wrong patient.
2.Documenting too little.
3.Documenting too much.
4.“X-ing” out of the screens instead of closing and logging out.
5.Failing to save/double click when adding chief complaint or medications.
6.Searching for orders instead of selecting from protocols.
7.Not reviewing chart for accuracy.
8.Failing to close chart at discharge.
9.Selecting cancel deletes everything you’ve entered at that time in the home page.
10.Patient weight not recorded. All Medications calculated using weight.


                                                          HEC
                                            Seven Stupid Things That Can’t Be
                                             Changed and Could Feel Sticky



1. Accucheck and Urine Dips will prompt a control # screen before you can enter value. Click OK to bypass this.
2. VS screen continue to prompts if you X-it must click return to charting
3. Cannot change physical assessment from NML to ABN. Must go to highlighted note, delete all, then change selection.
4. Documentation of simple comfort measures must be free text entries.
5. NG tube and foleys are only available in the RN procedure screen.
6. If charting any method in VS, must chart the method under assessment-will not display beside VS, but
   you can hover over
7. Using HEC, made us realize we needed this list.




HEC MD Training Manual                                                                                             45
                                        HEC
                                  Ten Commandments



1. Thou shalt not share passwords.

2. Thou shalt log off tracking board every time you walk away from computer.

3. Thou shalt confirm correct patient record is open before documenting.

4. Thou shalt close HEC patient record after documenting.

5. Thou shalt review “chart viewer” frequently to assure documentation matches your intent.

6. Thou shalt remain current with patient record throughout patient visit.

7. Thou shalt complete and sign chart upon patient disposition.

8. Thou shalt not develop “hyperclickosis.

9. Thou shalt not throw stones at HEC.

10. Thou shalt be patient with the super users.




HEC MD Training Manual                                                                        46
                                      1                                               2



Horizon Emergency Care                    CME:
                                          CME:
 HEC/HEO Integration                          This class is approved for 4 hours of
                                                     ti i      di l d      ti for
                                                 continuing medical education f
                                                 physicians.

                                              Please sign the CME Activity Record
   Physician Orientation                         of Attendance and remember to
                                                 collect your certificate at the
                                                 conclusion of class.
                   2008




                                      3



Agenda:                                   Patient Safety

    1.        g
         Background
    2.   ED Tracking Board
    3.   HEC: Using the application
    4.   Entering Orders with HEO
    5.   Managing Orders in HEC
    6.   Charting in HEC
    7.
    7                St dies
         Diagnostic Studies in HEC
    8.   Final Steps
    9.   Afterwards




                                                                                          1
Patient Safety Measures:                              Clinical applications:
• Right thing to do
                                                        • Improve patient safety
• Compliance issues                                     • Facilitate better decisions
• Reimbursement issues                                    ▫ Easier to do the right thing
                                                          ▫ Harder to do the wrong thing
CPOE: integral component of Patient Safety              • Automate repetitive processes
 initiatives                                              C a ge the        sequence of events
                                                        • Change t e pace & seque ce o e e ts




                                                                                                 8




Clinical applications:                                Definitions:
  • Not always faster- time neutral                      HOM (Horizon Orders Management):
  • Better documentation                                   Computerized Order Entry – Horizon
  • Help us do things we should have been doing all
                                                           Clinicals / Care Manager as used on
    along…
                                                           the Nursing Units

                                                         HEC (Horizon Emergency Care):
                                                           Online ED Clinical Documentation
                                                           Application




                                                                                                     2
                                               9                                                                                                      10


EDTB: TRACKING BOARD                                EDTB: Orientation
                                                                                                                   The two order/task alert column
                                                                                                                   names are:

                                                                                                                   RN To Do
                                                                                                                   SEC To Do

                                                                                                                   The alert messages in the
                                                                                                                   columns are “To Do” and
                                                                                                                   “Done”.

                                                                                                                   The columns are role specific,
                                                                                                                   however the alerts are tied
                                                                                                                   together. When an order has
                                                                                                                   one task, and that task is
                                                                                                                   completed by the secretary, all
                                                                                                                   the column alerts for that order
                                                                                                                   will toggle to “Done”.
                                                    The Tracking Board will show several areas of
                                                               f om HEC E amples a e
                                                    messaging from HEC. Examples are:

                                                    Chief Complaint –
                                                    Triage Level (color coded) –
                                                    Physician & Nurse assignments –
                                                    RN To Do –
                                                    Sec To Do –




                                               11                                                                                                     12



EDTB: Triage levels                                    EDTB: In The Waiting Room




          Names display in colors based on 5
          Level Triage:
             •Level 1- Blue
             •Level 2- Red                                                                          Patients in the waiting room must
                                                                                                    be re-assessed every 30 minutes,
             •Level 3- Yellow                                                                       cued by turning pink.
             •Level 4 – Green
             •Level 5 - Magenta




                                                                                                                                                           3
EDTB: Tasks & Messaging                                       EDTB: Tasks & Messaging




   To-Do lists:                                                 Lab:
       •ED RN                                                    Y- results available
       •ED Secretary                                              !- critical values
                                                                  *- results not seen by
                                                                provider

                       Task Status:                             Lab #: Counts number of labs
                          •To Do: Order pending in HEC          resulted (4/7 = 4 out of 7 labs
                          •In Prog: Order acknowledged          have been resulted)
                          •Done: Order completed




                                                         15                                       16


  EDTB: Sorted by Acuity/LOS                                    EDTB: Logging In




                                                                                                       4
                                                     17                                18


EDTB: View Unassigned                                     EDTB: Assign Patient




                                                     19                                20


EDTB: Launching HEC                                       HEC: Using the Application
         Select patient, then click on the CHART
         button or find CHART from the orders drop
         down menu to launch the Documentation
         Module.
         Module




                                                                                            5
                                                        21                                                                22


HOME PAGE                                                    USER PREFERENCES

                        h    h h      is       d h
                     When the chart i opened, the
                     clinician is brought to the main                           The clinician can select their personal
                     charting screen. This screen is                            viewing preferences from the Tools
                     called the “Home Page”.                                    drop down menu option. This
                                                                                selection opens up a window that
                     The home page has three tabs for                           allows the clinician to select their
                     the MD role.                                               default Chart Viewer view and
                                                                                default font size. This selection is
                     1) MD Charting                                             staff id specific and will remain the
                     2) Manage Orders                                           default setting for this user until
                     3) Chart Viewer                                            changed again.

                     The MD Charting tab is the default
                     view presented when launching
                     the chart.




                                                        23                                                                24


CLOSING THE CHART                                            PATIENT BANNER



                                                                                   Patient information is displayed at
                                                                                   the top of the home page. This area
                                                                                   is called the “patient banner”. It
                    There are three ways to close the                              displays the patient’s name and
                    home page.                                                     demographic information as well as
                                                                                   documented vitals and allergies.
                    1. From the Home Page screen, the
                       clinician can select “Return to TB”
                       from the file drop down menu
                       option.
                    2. From the Home Page screen, the
                       clinician can select “Exit” from
                       the file drop down menu option.
                    3. From the Home Page screen, the
                       clinician can chose “close” now
                       located in the upper right corner
                       of the home page.

                    (Note: Several screenshots in this
                    presentation are taken from older
                    versions and depict the ‘close’ button
                    in bottom right.)




                                                                                                                               6
                                                                      25                                                                26

      PATIENT INFORMATION                                                  ALLERGIES


                            By selecting the blue “i” option in the
                            patient banner area, the clinician can
                            view pertinent clinical information,                             Allergy information is placed at the
                            including height, weight, BSA and                                top of the home page in the patient
                            BMI, if both height and weight have                              banner. The allergy option turns red
                            been entered.                                                    if allergen information is present.
                                                                                             The clinician can hover over the
                                                                                             button and review the allergens or
                                                                                             click to add/review allergens.




                                                                      27                                                                28

      ALLERGIES                                                            SCREEN BEHAVIOR

                        Users can add or update allergens by
                        clicking on the allergy option.




If the patient
already has an
allergy entered, the
user will see this
pop-up to confirm
pop up
or add an allergen.
Otherwise, the                                                                                   There are many graphics in HEC.
“pick the allergen”                                                                              The user can hover their cursor
screen will show as                                                                              over a graphic to locate a hot spot.
seen on the right.                                                                               Clicking on the hot spot opens a
                                                                                                 charting path. The graphics
                                                                                                 typically are gender and age
                                                                                                 specific.




                                                                                                                                             7
                                                                                         29                                                                                                                           30


SCREEN BEHAVIOR                                                                               SCREEN BEHAVIOR
                                                                                              There are many charting “paths” within HEC. Typically, a user will want to select next to advance on a charting path
                                                                                              and to return to the home page. The user does not need to answer any questions on a screen to select next and
                                                                                              continue to the next charting screen.

                                                     h               l       i hi h
                                                    There are many places within the
       Search bar                                   application where a user will be
                                                    presented with a scrolling list.

                                                    Scrolling lists are typically
                                                                                              Next – advances the user on a charting path (preferred).
                                                    alphabetical. They have a search
                                                                                              Back - takes the user back to the previous screen.
                                                    bar at the top of the page that will
                                                                                              Cancel - cancels all charting that has taken place since leaving the home page.
                                                    bring the user to the desired area
                                                    on the list. Typing in a T will bring
                                                    the user to the T section of the list.

                                                    To make a selection on a scrolling
                                                    list, the user must DOUBLE click on
                                                                                                                                                             Red text indicates a forced
                                                    that selection. This moves the
                                                                                                                                                             question. The user will be
                                                    selection from the left column into
                                                                                                                                                             presented the message noted
                                                     h i h       l    i di   i   i h
                                                    the right column indicating it has
                                                                                                                                                             below if they select NEXT
                                                    been selected. To deselect an
                                                                                                                                                             before charting one option in
                                                    option, simply double click it in the
                                                                                                                                                             each area with red text.
                                                    right column.
                                                                                                                                                             Selecting Info Unavailable
                                                                                                                                                             allows the user to get past this
                                                                                                                                                             forced question.




                                                                                         31                                                                                                                           32


SCREEN BEHAVIOR                                                                               SCREEN BEHAVIOR

           Round options, also known as
           radio buttons, allow for only one
           selection.

           Square options allow for multiple
           selections.                                 … after text indicates to the
                                                       user that a follow-up
                                                       question will be presented.



                                                                                                There are many time stamps
                                                                                                through-out the application. The
                                                                                                application will default to the
                                                                                                current time. McKesson
                                                                                                                                                                                This type of screen allows the user
                                                                                                recommends point of care
                                                                                                                                                                                to select and deselect their
                                                                                                charting, but if necessary, the user
                                                                                                                                                                                charting options by clicking on the
                                                                                                     h       h i      by      lli
                                                                                                can change the time b scrolling
                                                                                                                                                                                black text. Note: the selection
                                                                                                the numbers on the time stamp.
                                                                                                                                                                                turns yellow, indicating the
                                                                                                                                                                                selection made, and the sentence
                                                                                                                                                                                appears below that option in bold
                                               ___ within the text
                                                                                                                                                                                text.
                                               indicates to the user that a
                                               fill-in-the-blank question
                                               will be presented.




                                                                                                                                                                                                                           8
                                                                33                                                     34


                    SCREEN BEHAVIOR                                  ENTERING ORDERS: HOM




The blue info link can bring the
user to a web page with more info
about the medicine or procedure.




                                                                35                                                     36



 Search for an item:                                                 Answer any order prompts:
                                      Enter a search keyword                                 Choose from a drop
                                      and click Search.                                      down or fill in any
                                      Choose your order                                      outstanding order
                                               Select Orders”
                                      under “Select Orders                                   prompts. As you satisfy
                                      that you want and                                      the prompt, the blue
                                      double click or click                                  flag goes away. You
                                      once and click on “Add                                 can tell which orders
                                      to List”                                               have prompts in the
                                                                                             “Orders to Be Entered”
                                                                                             box as they have a blue
                                                                                             flag behind the order
                                                                                             name.




                                                                                                                            9
                                                   37                                                    38



Order Sets:                                             Cancelling an order:
                       Choosing the Order Sets                                 If you decide you don’t
                       button lists sets of                                    want an order or you
                       orders you can select                                   order something by
                       based on the description                                mistake, click the
                       of the set.                                             MODIFY button and
                                                                               either 1) change the
                       Caution!: Double                                        order (in this case
                       clicking the order opens                                perhaps change the
                       the Order Set Details                                   dose of Morphine to
                       with every order                                        4mg instead of 10mg
                       checked. This is                                        or 2) click the CANCEL
                       probably not what you                                   ORDER button.
                       want with most order
                       sets.

                       Clicking the DETAILS
                       button opens the Order
                       Set Details with all the
                       orders unchecked and
                       you can just check the
                       ones that you want




                                                   39                                                    40



Signing your orders:                                         MANAGING ORDERS
                       When you are done
                       entering orders, click
                       the SIGN button at the
                       bottom of the Entered
                       Orders box. If you don’t
                       sign them now, you will
                       be asked by the
                       application to sign them
                       when you disposition
                       the patient later.

                       If a nurse or other staff
                       member has entered an
                       order for you, as a
                       standing order perhaps,
                       you will need to sign
                       those also.




                                                                                                              10
                                           41                                                42


MANAGE ORDERS                                   MANAGE ORDERS
                Selecting the “Manage                             The highlighted order
                Orders” tab will bring                            is displayed in the
                the clinician to the                              circled area. This
                manage orders screen.                             detailed area tells the
                From this screen the                              clinician who placed
                clinician can manage                              the order and gives a
                and view the orders that                          summary of how
                have been placed for                              many orders are new
                this patient during this                          or unsigned by the
                patient encounter. They                           physician.
                also have the option of
                entering orders,
                modifying orders, and
                signing orders.




                                           43                                                44


MANAGE ORDERS                                   ORDER STATUS
                 Users can rearrange
                 and resort the orders
                 and order columns on                           The manage orders tab is
                 the manage orders                              where the clinician will go to
                 screen.                                        view the status of all orders
                                                                and manage the orders.
                 Clicking on any of the
                 column names will                              The status of orders change
                 resort the order list.                         with the completion of these
                                                                orders. Ancillary orders will
                 You can also grab a                            now be completed by the
                 column and move it                             ancillary system, like lab,
                 by left clicking and                           and that will message to the
                 holding on the                                 status column on the
                 column name you                                “Manage Orders” screen.
                 wish to move and
                 dragging it to the                             Completed orders fall to the
                 place you wish it be.                          lower part of the list of
                                                                orders. New orders stay at
                 It is important to note                        the top of the list. By
                 that the rearranged                            clicking on the word “status”
                 columns persist                                one can re-sort these orders,
                 across all roles and                           as desired.
                 users for this patient
                 encounter.




                                                                                                  11
                                                        45                                                                      46


             TASKS                                                              COMPLETING ORDERS
                        If there is a task to be
                        completed for an order, the
                        role of who can complete
                        that task will be in the task
                        column.                                                                       If there is an order to be
                                                                                                      completed, the hierarchical
                        The “Tech+” in the example                                                    role of who can complete
                        shown, indicates that a Tech                                                  that order will be in the
                        or RN can complete these                                                      complete column.
                        tasks.
                                                                                                      The “RN+” in the example
                        Once the Tech has completed                                                   shown, indicates that an RN
                        all tasks and orders that they                                                can complete this order.
                        can do for this patient, the
                        “Tech to Do” column on the                                                     An order may be completed
                        Tracking Board will change                                                    in two ways.
                        from “To Do” to “Done”.                                                       1) Highlight the order and
                                                                                                      select the complete option
                        A task may be completed in                                                    near the top of the manage
                        two ways.                                                                     orders screen.
                        1) Highlight the order and                                                    2) Click in the complete
                        select the task option near                                                   column for that specific
                        the top of the manage orders                                                  order.
                        screen.
                        2) Click in the task column
                        for that specific order.




                                                        47                                                                      48


Charting in HEC                                                  ADD MEDICAL PROBLEM


       Less Is More…
       L    I M
   Resist the urge to click
         every item.
                                                                     h    dd      bl       i
                                                                    The Add a Problem option
                                                                    provides access to add a chief
                                                                    complaint. The chief


      “Chart by Exception”
                                                                    complaint drives the history
                                                             The Add a Problem option
                                                                    charting flow. Typically, users
                                                             allows the provider to add a
                                                                    should enter just one chief
                                                             chief complaint. The chief
                                                                    complaint.
                                                             complaint drives the history
                                                             charting flow. Typically, users
                                                             should enter just one chief
                                                             complaint.




                                                                                                                                     12
                                                                                                                               49                                                                                           50

                                                                                                                                     HPI:
                                                                                                                                     HPI:
        ADD MEDICAL PROBLEM                                                                                                          DOCUMENTATION STARTS HERE!
                          There are two ways to choose a chief complaint.


                                                                                                            2) The user may
1) The user may
                                                                                                            select a chief
select a chief
                                                                                                            complaint by
complaint for soft
                                                                                                            double-clicking
tissue problems or
                                                                                                            from a scrolling list.
injuries by clicking
the graphic picture
on the affected area.


                                                                                                NOTE: It is important for
                                                                                                users to select a chief
                                                                                                complaint from the
                                                                                                graphic ONLY if the
                                                                                                complaint is a soft
                                                                                                 i    /l    li j
                                                                                                tissue/local injury
                                                                                                problem. Otherwise, the
                                                                                                                                     The HPI option brings the user to the History and
                                                                                                user should always use
                                                                                                                                     Physical Exam screen. Clicking on HPI marks the
                                                                                                the med/surg scrolling
                                                                                                                                     start time of the encounter in HEC.                 NOTE: If a chief complaint has
                                                                                                list.
                                                                                                                                                                                         not been selected for this
                                                                                                                                      This is where the user will see how the chief      patient encounter, the user will
                                                                                                                                     complaint drives the history documentation. In      be presented with the chief
                                                                                                                                     the example shown above, the chief complaint of     complaint graphic first.
              The selected Chief Complaint displays in the text box under MEDICAL/SURGICAL                                           “Abdominal Pain” presents the Quick Chart-GI
                                                                                                                                     Problems and ABD. PAIN-N/V-Diarrhea-HERNIS-
                                                                                                                                     ETC options. Clicking on either of these options
                                                                                                                                     allows the user to document the subjective and
                                                                                                                                     objective data surrounding this chief complaint.




                                                                                                                               51                                                                                           52

                                                                                                                                     HPI:
                                                                                                                                     HPI:
       HPI: Structured History
       HPI:                                                                                                                          Review Nursing Notes, Records




                                                                                                                                                                                              Checking the “nursing note
                                                                                                                                                                                              reviewed…” will assist with
                                                                                                                                                                                              coding as the coder may use
                                                                                                                                                        Check the buttons and/or boxes        nursing documentation to
                                                                              Selecting the chief complaint (s) drives the                              regarding nursing notes and           justify coding.
                                                                              application to present various structured                                                 Discrepancy
                                                                                                                                                        record review. “Discrepancy
                                                                              histories and “Quick Charts.”                                             noted” will open a text box to
                                                                                                                                                        describe any discrepancy
                                                                              Preferred “Quick Charts” may include:
                                                                                     •UTI
                                                                                     •URI
                                                                                     •Sickle Cell
                                                                                     •Back Pain
                                                                                     •Sepsis
                                                                                     •Kidney stone
                                                                                     •Toothache
                                                                                     • Chest Pain




                                                                                                                                                                                                                                 13
                                                                 53                      54


PMH-FH-SH-ROS:
PMH-FH-SH-ROS:                                                        ROS:
                                                                      ROS:



                                  Past Medical History, Family
                                  History, Social History and
                                  Review of Systems may be
                                  accessed from this location.




Structured history and charting
pathways may appear based
upon primary complaint.




                                                                 55                      56


     HX:
PAST HX:                                                                           HX:
                                                                      PAST MEDICAL HX:




                                                                                              14
                                                  57                                      58


              HX:
PAST SURGICAL HX:                                           QUICK CLICK EXAM


                                                       The Quick Click Exam
                                                       option is found only on the
                                                       History and Physical Exam
                                                       screen. This exam allows
                                                       the user to document
                                                       quickly pertinent positives
                                                       and negatives of their head-
                                                       to-toe exam.

                                                       This is an excellent means
                                                       of easily and quickly
                                                       documenting physical
                                                       findings f most
                                                       fi di    for
                                                       presenting complaints.




                                                  59                                      60


SOFT TISSUE EXAM                                            PMH-SH-
                                                            PMH-SH-FH




                    The Soft Tissue Exam option
                    presents the user with several
                    options for documenting a soft
                    tissue exam. This area is
                    generally used to document
                                                                The PMH-SH-FH option
                    traumas or injuries. This
                                                                allows the user to
                    option can also be found on the
                                                                document past
                    Physical Exam screen.
                                                                medical/surgical/social
                                                                history, as well as a
                                                                review of systems.




                                                                                               15
                                                                                                                                   61                                                                                               62


    PHYSICAL                                                                                                                                                                 PHYSICAL EXAM
                                                                                                                                        Selecting NL on the
                                                                                                                                        General Physical Exam
                                                                                                                                        screen brings default
                                                                                                                                        normal text return into
                                                                                                                                        the medical record.
                                                                                                                                        Selecting ABN will bring
                                                                                                                                        the clinician to follow-up
                                                                                                                                                  h    ll    b h
                                                                                                                                        screens that allow both
                                                                                                                                        normal and abnormal
                                                                                                                                        charting options.




                                                                                                                                                                                                       Selecting My Defaults
                                                                                                                                                                                                       and clicking on one of the
                                                                                                                                                                                                       exam types checks NL on
                                                                                                                                                                                                       some of the systems.
                                                                                                                                                                                                         See the next slide




The Physical option
brings the user to the
General Physical Exam
screen. NOTE: There are
several other exam
options near the top of
this screen.




                                                                                                                                   63                                                                                               64



    MY DEFAULTS                                                                                                                                VITALS SUMMARY
My STANDARD Normal Exam returns the following normal values:
General Presentation
ENT Exam
Eye Exam
Pulmonary Exam
Cardiac Exam
Abdominal Exam
Skin Exam
Psychiatric Exam (Neuro-Psychiatric)

My EXTENDED Normal Exam returns the following normal values:
General Presentation
ENT Exam                                                                          My STROKE Normal Exam returns the following normal
Eye Exam                                                                          values:
Pulmonary Exam                                                                    General Presentation
Cardiac Exam                                                                      ENT Exam
Abdominal Exam                                                                    Eye Exam
Neuro Exam                                                                        Pulmonary Exam                                                                     Vital signs allows the user a
Psychiatric Exam (Neuro-Psychiatric)                                              Cardiac Exam                                                                       view of all vital signs entered
SKIN- you must select the values, it does not return a default normal statement   Abdominal Exam                                                                     on one screen. From this
                                                                                  Neuro Exam                                                                                     h       i l i
                                                                                                                                                                     summary sheet, vital signs can
My CARDIAC Normal Exam returns the following normal values:                       Psychiatric Exam (Neuro-Psychiatric)                                               be added, modified or deleted.
General Presentation
ENT Exam                                                                          My TRAUMA Normal Exam returns the following normal
Eye Exam                                                                          values:
Pulmonary Exam                                                                    General Presentation
                                                                                                                                            Vitals summary allows the user
Cardiac Exam                                                                      ENT Exam
                                                                                                                                            a view of all vital signs entered
Abdominal Exam                                                                    Eye Exam
                                                                                                                                            on one screen. From this
Psychiatric Exam (Neuro-Psychiatric)                                              Pulmonary Exam
                                                                                                                                            summary sheet, vital signs can
                                                                                  Cardiac Exam
                                                                                                                                            be added, modified or deleted.
                                                                                  Abdominal Exam
                                                                                  Musculoskeletal Exam
                                                                                  Psychiatric Exam (Neuro-Psychiatric)




                                                                                                                                                                                                                                         16
                                           65                                                               66


VITAL SIGNS                                     VITAL SIGNS
              By selecting ADD VITAL SIGNS,                             By checking the box under each
              the user is presented the vital                           of the vital signs, these follow-
              sign graphic. This is where                               up questions appear.
              new vital signs can be entered.




                                           67                                                               68


VITAL SIGNS                                     VITAL SIGNS

                  h li i i
                The clinician may
                click anywhere on
                the pain scale to
                indicate the patients
                level of pain.




                                                   NOTE: The user
                                                   must document
                                                   VS for supine and
                                                   standing positions
                                                   to obtain Delta
                                                   score.




                                                                                                                 17
                            69                               70


   VITAL SIGNS                      VITAL SIGNS




                            71                               72


   PATIENT UPDATE                   FREE TEXT NOTE




Patient Update brings the        The Free Text Note
user to the Update Note          option allows the user to
screen. This is where the        choose which heading a
documentation of the             free text note will be
transfer of care and new         placed under.
problems while in the
department occurs.




                                                                  18
                        73                                                                    74



HEC: Transfer of Care        HEC: Transfer of Care




                        75                                                                    76



HEC: Transfer of Care        HEC: Transfer of Care




                                                Documentation of transfer of care in HEC is
                                                not automatically communicated to EDTB;
                                                this must also be entered into EDTB by the
                                                provider.




                                                                                                   19
                                                                          77                                                      78


                             CHART VIEWER                                      HEC: DIAGNOSTIC STUDIES

                                               All roles
                                               (MD/RN/PA/NP/Tech/UC)
                                               have a tab called Chart
                                               Viewer.

                                               The Chart Viewer tab
                                               allows the clinician to
                                               select a view other than
                                               their default view to
                                               display the current
                                               charted data.




                                                                          79                                                      80


  LABS                                                                         ABG:




                                                                                      Allows you to enter the ABG results for a
                                                                                      patient and interpret them within your
                                                                                      documentation




When selecting the Labs option, if there are
labs to be reviewed, the user will be
presented a Lab Results Summary. If no lab
results are available, or the labs have
already been reviewed, the user will see the
message to the right. Reviewed labs adds to
the complexity and decision making at the
CMS audit at disposition. Providers should
view labs in HEC rather than EDTB or portal
to ensure documentation of data review.




                                                                                                                                       20
                  MEDICAL IMAGING                                                                           MEDICAL IMAGING
  The Physician selects XRay from the link on the left side of the screen.   Xrays ordered in HEO will appear in this interpretation box. The physician
                                                                             selects the Interpret Button for the x-ray they wish to document their
                                                                             interpretation on…




                                                                                                                                                                     84


                  MEDICAL IMAGING                                                 EKG
There are approx 160 follow up questions (some are still in development)
for radiology interpretation.




                                                                                                                                        Selecting “more specific
                                                                                                                                        documentation” brings the
                                                                                                                                        user to the Master EKG
                                                                                                                                        Interpretation Work Sheet.




                                                                               The EKG option allows
                                                                               the user to document
                                                                               their interpretation of an
                                                                               EKG or rhythm strip.




                                                                                                                                                                          21
                                                                                                    85                                                    86



      EKG                                                                                                    FINAL STEPS


                                                                           This is the Master EKG
                                                                           Interpretation Work
                                                                           Sheet.

                                                                           The graphic shown on
                                                                           the left opens a charting
                                                                           path to document
                                                                           specific findings of the
                                                                           EKG waves.




                                                                                                    87                                                    88



      ADD DIAGNOSIS                                                                                          PROCEDURES




The Add Diagnosis option presents the user with a scrolling list of
diagnoses.

If a diagnosis has not been generated in documentation prior to
discharge, the user has the option of selecting a diagnosis here for the
patient encounter.                                                                                       The Procedures option presents the user with a
                                                                                                         scrolling list of procedures to document.
If no diagnosis has been selected, clicking on “Disposition” will offer
the user a list of diagnoses based upon previously entered                                               Many procedures will already have been
documentation.                                                                                           documented in earlier workflows.




                                                                                                                                                               22
                                                                                                89                                                                                                                                                90

                                                                                                          Attending Physician reviewing a Resident
    REVIEW                                                                                                or Medical Students documentation


                                                                                                      Choose CONSULT NOTE




                          Review provides access to chart review,
                          other reviews, and provider assignments.
                          The Provider Assignments option is used
                          by NP’s, PA’s, DO’s and Residents that
                          need to have a co-signing MD. See pages
                          ___ for examples.

Review provides access to chart review,                                                              Produces in the chart:
other reviews, and provider assignments.                                                             Consultations
The Provider Assignments option is used                                                              Have reviewed the available ER record. I was present and materially participated in this patient's care as follows: I reviewed and confirmed with
by NP’s, PA’s, DO’s and Residents that                                                               corrections and additions as noted in the record the Resident/PA/ARNP medical history, physical exam, diagnostic tests, diagnostic test
need to have a co-signing MD.                                                                        interpretation, assessment, diagnosis, and discharge plan. I reviewed and directed the Resident/PA/ARNP Emergency Department patient treatment.
                                                                                                     I performed procedures as noted in the record. EMERGENCY DOCTOR MD - Electronic Signature. At this point I agree with the current assessment
                                                                                                     done in the Emergency Department. The most likely diagnosis at this point is Chest pain.




                                                                                                91                                                                                                                                                92

    DISPOSITION                                                                                                DISPOSITION: Diagnosis




                                                                     From the Disposition
                                                                     screen, the user can add
                                                                     or change the diagnosis,
                                                                     critical care time,
                                                                     prescriptions, and
                                                                     discharge instructions.

                                                                     The CMS audit is
                                                                     accessible only when the                           If a diagnosis has not been documented,
                                                                     audit level does NOT                               the user will first be presented with a list
                                                                     match the recommended                              of possible diagnoses. The last selection
                                                                     level.                                             on this screen is the diagnosis scrolling
                                                                                                                        list.




                                                                                                                                                                                                                                                         23
                                                                                 93                                                                                     94


 DISPOSITION: CMS Audit                                                                       DISPOSITION: CMS Audit

                            When the physician makes the decision to
                            disposition a patient, they go to the
                            disposition screen within HEC
                            Documentation Module.

                            From this screen, the physician can view the
                            current E/M audit level for this encounter.
                            The application will notify the physician what
                            E/M level their documentation currently
                            supports and potentially what level this visit
                            supports,                                                         here
                                                                                       From here, the physician may review a
                            could be coded at, based on the diagnosis                  tally sheet of audit criteria, and
                            codes generated during the documentation                   evaluation screen is displayed.
                            of the encounter.
                                                                                       From this screen the application offers
                                                                                       suggestions on areas of documentation
                                                                                       needing more detail to raise the CMS
                                                                                       Audit level.




                                                                                 95                                                                                     96


 DISPOSITION: Follow-up
              Follow-                                                                 DISPOSITION: Prescriptions

                                               The default setting for all
                                               follow-ups is 3-5 days, but can
                                               be changed by deleting the 3-5
                                                  d inserting the d i d text.
                                               and i      i    h desired




                                                                                                                                           NOTE: Work and school note
                                                                                                                                           options are found under MY
                                                                                                                                                      RX S.
                                                                                                                                           PERSONAL RX’S.



The Disposition screen
should be completed in a
                                                                                      Prescriptions can be written from the Home
systematic way, so as not                                                             page or the Disposition Screen.
to miss any areas of
documentation.                                                                        Prescriptions are grouped for efficiency. The
                                                                                      ALL OTHER medications in the bottom right
                                                                                      corner presents a scrolling list of prescriptions.




                                                                                                                                                                             24
                                                                 97                                                                                   98

DISPOSITION: Instructions                                                  DISPOSITION: Instructions




                                                                                                         The user may select individual reports to
                                                                                                         print or choose Full Chart to print the
                                                                                                         chart in its entirety.

                                                                                                         If discharge instructions are included in
                                                                                                         selected reports to print and have yet to
                                                                                                         be selected, the application will prompt
                                                                                                         the user to select appropriate discharge
                                                                                                         instructions .

                                                                                                         Discharge instructions, prescriptions
                                                                                                         and/or work or school excuses will be
                                                                                                         placed in discharge basket when patient is
                                                                                                         ready for discharge.




                                                                 99                                                                                   100

DISPOSITION: Instructions                                                  DISPOSITION: Final Steps


                      DO NOT select a discharge instruction
                      from the list presented as UTMC is using
                      another Discharge Instruction program
                      superior to the instructions in HEC.
                      Choose CLICK HERE TO ENTER CUSTOM
                      INSTRUCTIONS and fill in the box.               Mandatory Input:
                      Enter any diagnosis you would like an
                      instruction sheet generated for an then
                                                                      •Patient Disposition
                      enter any specific instructions you want
                      the discharging nurse to add to what is
                                                                      (opens secondary dialog
                      given to the patient.                           with admit or transfer)
                                                                      •Condition at Disposition
                                                                      (required by JCAHO)         MD signs off orders and
                                                                                                        here-
                                                                                                  chart here- Signing chart
                                                                                                  closes documentation.

                                                                                                  Do NOT check “Close
                                                                                                  Out RN Charting.”




                                                                                                                                                            25
                                                                                    101                                                                                                      102

  DISPOSITION: Final Steps                                                                DISPOSITION: Printing




                                           If patient is to be discharged,
                                           place prescriptions, instructions
                                           and/or work and school excuses
        Prescriptions, can be printed by   in discharge basket.
                   Print       Report.
        selecting “Print Other Report ”

                                                                                            The Print/Fax option provides access for the user to print
                                                                                            instructions and prescriptions as well as print or electronically fax
                                                                                            the medical record. Ideally, Prescriptions would be printed at the
                                                                                            end of the disposition screen.




                                                                                    103                                                                                                      104

  DISPOSITION: FAX Charts
                                                                                                               CHART FINDER
                                                 The user may select a Chart
                                                 View report to fax from the                                                     From the Tracking Board, the user can
                                                 scrolling list. A cover sheet is
                                                 sent with each fax, and the                                                     go to the drop down menu under Orders
                                                              dd
                                                 user may add comments, if
                                                 desired, to the cover sheet.                                                    to HEC Patient Chart Finder. With this,
                                                                                                                                 the user can:
                                                                                                                                 •find discharged patients’ charts
                                                                                                                                 •add free text addendum notes
                                                                                                                                 •check for unsigned charts
                                                                                                                                 •assign charts to another physician for
                                                                                                                                 signature
                                                                                                                                                    NOTE: It is recommended that all users
                                                                                                                                                    check their unsigned chart cue at the
                                                                                                                                                    end of each shift, to be sure all
                                                                                                                                                    documentation for the day is complete.
After selecting items to be
printed, the user may select
an ED printer destination.




                                                                                                                                                                                                   26
                                       105                                                             106



                        CHART FINDER               FINDER-
                                             CHART FINDER- Finding Charts




                                                                 This query searched all charts with the
                                                                 last name of Patient. By highlighting the
                                                                 appropriate chart, the user can select to
                                                                 launch the chart as shown at the bottom
                                                                 of the screen.

                                                                  O      hi d
                                                                 NOTE: This drop d         i    ll    h
                                                                                  down option allows the
                                                                 physician to choose the cosign chart
                                                                 option.
Once Chart Finder is
launched, the user
can choose a list or
search, or query all
charts with a certain
status.




                                       107                                                             108


               FINDER-
         CHART FINDER- Addendums                    FINDER-
                                              CHART FINDER- Addendums

                                                                              When the selected chart
                                                                              is launched from chart
                                                                              finder, if it is a
                                                                              closed/complete chart
                                                                              the chart will be opened
                                                                              in addendum mode. This
                                                                              is where users can
                                                                              document any
                                                                              care/interventions that
                                                                              happened after the
                                                                              patient left. The
                                                                              addendum mode charting
                                                                              allows for only free text
                                                                              entries.




                                                                                                             27
                         109                                        110
      FINDER-
CHART FINDER- Changing                 FINDER-
                                 CHART FINDER- Changing
   Assigned Provider                Assigned Provider




                         111                                        112
      FINDER-
CHART FINDER- Changing
   Assigned Provider
                               Summary:
                                  1.              g
                                       ED Tracking Board
                                  2.   Using the application: HEC
                                  3.   Entering Orders: HEO
                                  4.   Managing Orders in HEC
                                  5.   Charting in HEC
                                  6.   Diagnostic Studies in HEC
                                  7.
                                  7    Fi l Steps
                                       Final St
                                  8.   Afterwards




                                                                          28
                                                        113                                              114



Practice Cases:                                                       A Final Request:
 1. Group documentation: case #1. We’ll step through
    this case together.                                       • Remember to pick up your CME
                                                              certificate
 2. Nursing personnel have entered a variety of
    patients into the system with nursing
    documentation and some orders in progress.                • Please take time to fill out the
    Attendees will be assigned patients and scenarios         questionnaire distributed with today’s
    to practice documentation and order entry.                materials.

 3. Quick-registration of patients into EDTB for
    documentation-only practice
                                                              • Your feedback will help us improve
                                                              efforts at facilitating this transition.




                                                                                                               29

								
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