PCS/BMV Implementation RN PAT, SDC, PACU Session I

PCS/BMV Implementation RN PAT, SDC, PACU Session I

PCS/BMV Implementation RN PAT, SDC, PACU Session I Acronyms PCS: Patient Care System Documentation Interventions Agenda PCS: Patient Care Systems

Overview Status Board Worklist Documentation Functions Nursing Main Menu List of Routines and Reports PCS Status Board will provide most nursing care routines Status Board

PCS Status Board Patient Assignment List Status Board Function Buttons Patient Assignment List/Home Page Displays Pertinent Patient Information

Relevant to the particular patient location ie: Psych, MedSurg, Rehab, etc Continuously Refreshes with new information (every 5 minutes) Launching pad to various patient care routines Patient Care Routines & Function Buttons My List Manually Add Patients to your list Pts are Retained From One Log-on to the Next

Discharged Patients Remain on your Status Board until manually removed Enables Care Provider to Complete Documentation even after the patient has left the facility Manually Remove Patient from your List Once you have Completed your Documentation and the patient has been discharged (or you are leaving for the day) The more patients on your List the longer the status

board will take to load Adding Patients to your List [Lists] Button provides options to search for and add patients to your List Find Account Search for single patient by patient name Find Patient by Outpatient Location Provides a list of patients assigned to each location

Provides the ability to add multiple patients to your list at one time Preferred method My List Launches your patient assignment list Video Demonstration II PCS Status Board PCS Status Board Exercise A: Find Patient by Location 1.

2. 3. 4. 5. 6. 7. 8. 9. Click [Lists] Click [Find Patient by Outpatient Location]

Select [SDC.DSMH (Day Surgery) Location] Click [Assignments] - Right hand panel Place a checkmark to the left of two patient names Click [Add to My List] -Footer Button Click [Lists] - Right hand panel Select [My List] Confirm that both patients have been added to your assignment list Exercise B: Find Patient by Account 1. Click [Lists]

2. Click [Find Account] 3. Type Patients Name (Last Name, First Name) Use the Patient Assigned to you by your Instructor 4. Click to the select the patient account Select the Account Number with the REG SDC Registration Type The status Board will Appear

Click [Add to My List] Footer Button Click [Lists] Select [My List] Confirm this new patient has been added to your List Open Chart Open Chart

All Inclusive Nursing Care Routine Review Patient Data Complete Assessment, Outcome, and Medication Documentation Enter Orders Enter Allergies and Home Medications Open Chart EMR Electronic Medical Record Review Patient Data OM Order Entry

EMR Enter Orders PCS Patient Care System MAR Medication Administration Record Document Medications OM

Worklist Intervention & Outcome Documentation Write Note Clinical Data Enter/Review Patient information PCS Worklist

Worklist Open Chart Routines Worklist Worklist Functions

Open Chart defaults to the worklist tab Documentation Routine Interventions, Assessments, & Outcomes Worklist: Standard of Care Upon registration a Standard of Care Automatically defaults Contains Standard Interventions most locations document

Only document the Interventions which pertain to the Surgical Areas Care Plan Process: New Admission 1. Launch the Open Chart Use Patient Assigned to you by your instructor 2. Confirm the Standard of Care Displays 3. Add the Standard of Care: *PAT/Amb - Day Surgery Admit-Set

Click Add Select the Standard of Care Tab Click *PAT/Amb Day Surgery Admit-Set Click Save 4. Confirm the following Interventions display

Ambulatory/Day Surgery Adm Information Columbia Suicide Risk Rating Scale

IV/Invasive*Line Assessment PACU Holding Area-Inpt/ED Preop Note PACU*Record Past Medical History Phase II/*Outpt Post Procedure Recovery Post Surgical Consult Review Pre-Adm Testing (PAT) Admission Info Pre-Surgical Documentation Reviewed Skin Assessment Sort by Frequency

Clicking the Frequency header will sort the list by frequencies Documentation Overview Documentation Overview Documentation mode defaults to flow sheet Provides a view of prior documentation Mode Button will toggle to Questionnaire mode

Similar to a paper assessment Documentation Flow sheet Mode Current Date/Time Defaults Gray Background = View Mode White Column = Documentation Mode

Documentation - Questionnaire Clicking Mode will toggle to Questionnaire Style You may toggle between Questionnaire and Flow sheet mode at any time within documentation Video Demonstration IV Documentation Documentation

Exercise D: Documenting PMH 1. Start from the worklist 2. Place a checkmark in the now column 3. Click [Document] Confirm the time column displays the current date/time in the header Review the documentation Displaying from the last admission 4. Click [Mode] to toggle to Questionnaire Mode 5. Document PMH: Asthma, Diabetes- Insulin Dependant, Tuberculosis, Eczema, Epilepsy, Patient is not at risk for aspiration

6. Any Body Systems with a Negative Response should be documented 7. Click [Save] 8. Confirm the last done column updates with the last time the intervention was documented EMR Patient Care Panel Displays PCS Documentation Assessments Interventions

Outcome Care Plan Exercise E: Reviewing Documentation - EMR

Click [Patient Care Panel] Confirm that the [Assessment] Tab Defaults Click the [Name] Tab This simplifies the list of Assessments Select to view the Past Medical History Documentation Place a Checkmark to the left of the Assessment Name Click [View History] Confirm that all documentation displays

Click [Back] Click [Plan of Care] Tab Header Click the [+] Symbol (in the description header) to Expand the Components of the Care Plan Review the Care Plan Components Documentation Functions Documentation Functions

Temperature Query Enables you to toggle between Fahrenheit and Centigrade Height and Weight Queries Allows users to toggle between Metric and English Instance Type Queries Documentation Functions Enable multiple instances of documentation for various body locations or situations o IV Insertions, Orthostatic Vital Signs, etc

Documentation Calculator Temperature Temperature Query Enables you to toggle between Fahrenheit and Centigrade Will always default to Fahrenheit Documentation Calculator for Height and Weight

Enables you to toggle between English and Metric Units Regardless of the units of documentation, the display will default to Metric Documentation Instance Type Document the fields for the situation/instance Repeat the instance type documentation for the new body location In this case, BP and Pulse will be documented for Lying, Sitting, and Standing Positions

Documentation Back Time To back date/time your documentation, click the drop down arrow in the header Adjust the date/time to reflect when the data was collected Documentation Expand/Collapse Clicking the [-] symbol will collapse the field

within the section Documentation Collapse Notice the temperature section is now collapsed You may now click the [+] symbol to expand Some sections will default as collapsed Notice the Thermal Management Documentation defaults this way and can be expanded as needed Documentation that is infrequently utilized will default as collapsed and must be manually expanded as needed The Manual Expand/Collapse will stick for the current assessment only

Exercise F Part A: Documentation Functions - Back Documenting Select the [worklist] routine Select Vital Signs

Click in the now column for the Vital Signs Click [Document] Back Document 1 Hour in the Past In the Header, click the drop down to the right of the Date/Time Field Change the time to 1 hour in the past Next Step Next Slide Exercise G Part B Documentation Functions Calculator & Instance Type

Document Temperature: 98.6 Oral Pulse: 62 Orthostatic Vital Signs (Instance Type) Click New Orthostatic Vital Signs to start a new instance Lying Left Arm 120/80 Pulse 62 Click New Orthostatic Vital Signs to start a new instance Sitting 118/78 Pulse 63 Click New Orthostatic Vital Signs to start a new instance

Standing 115/70 Pulse 65 Click [Save] Exercise H: Review Documentation in EMR Select [Patient Care Panel] in the EMR Place a checkmark to the left of the Vital Signs Assessment Click View History Confirm that the Vital Sign Assessment displays under the adjusted time (1 hour in the past)

Click [Back] Click the [Vital Signs] Panel of the EMR and review the documentation Recall Values Recall Values Recall Values provides the ability to pull prior documentation to the current assessment To invoke the recall values function, click the [Recall] Button

Recall Values Recalls the entire assessment Recalls the section Recalls the individual query

Assessment displays in green A column of diamonds appear to the right Select the diamonds to recall individual queries, entire sections, or the whole assessment It is critical that you review the recalled information to ensure accuracy before saving Recalling & saving = Signing your name to the documentation

Exercise I: Recall Values Document Past Medical History Click in the now column to select the intervention Click Document Click Recall Notice the screen turns green and diamonds appear in the right hand column Click to recall one query: select to the right of the cardiovascular history Click to recall the section: select to the right of the cardiovascular past medical history

Click to recall the entire assessment: select to the right of the Past Medical history Confirm the entire assessment has recalled Review all documentation to ensure accuracy Update the GI Past Medical History Query Click Save Worklist Management Worklist Additional Functions

Item Detail: Protocol, Associated Data, Item Detail Info Care Item: Intervention, Assessment, Outcome Frequency Worklist displays active and discharge statuses by default All other statuses are suppressed from view Last Done Status

Item Detail Item Detail Column Item Detail Column P: Protocol A: Associated Data I: Item Detail Item Detail

Clicking the Icons will launch the item detail screen Within Item Detail there are multiple tabs Detail, History, Flow sheet, and Associated Data Item Detail Tabs Detail Info about Intervention Intervention text (Post it note)

History Audit trail of changes made to the intervention Flow sheet Documentation View in Flow sheet mode Associated data View of Data Fields related to the particular intervention Item Detail History Tab

Audit Trail of Changes Made to the Intervention Activity: Document, Edit, Undo User that documented, Care Provider Type, and Detail related to the change Footer buttons: Edit/Undo documentation Allows you to edit or undo your own documentation only You may not edit or undo another users documentation Item Detail: Info Item detail may be utilized as a communication tool

In the text field enter a note related to the intervention In this case, the patients blood pressure must be taken on the left arm Item Detail: Edit Text Enter the text that you wish to display with the intervention Click save Item Detail Text The item detail will be viewable by

clicking the I from the worklist or within the assessment Video Demonstration VII Item Detail/Editing & Undoing Documentation Item Detail Edit and Undo Exercise I: Item Detail/Editing

Locate the Pain Intervention Click the P to invoke the Pain Protocol Review the Protocol Click [Back] to return to the worklist Find the Vital Signs Intervention Click in the [Item Detail] Column Select the [History] Tab Select the last instance of documentation Click [Edit] Document that the patient is on room air and O2 Sat is 98%

Click [Save] Confirm a new Edit Line Item displays Click in the detail column for the edit line item to review the old and new results Exercise J: Item Detail Text For the vital signs intervention, indicate that the blood pressure must be taken on the left arm Click in the item detail screen for the Vital Signs Intervention Click the [Detail] Tab In the text field, click [edit]

Type: Patients blood pressure must be taken on the left arm Click [Save] Click [Back] to return to the worklist Click the I in the item details screen to view the information Click [Back] to return to the worklist Please note: The last documented text will print with the medical record Editing Worklist Frequencies To edit a frequency, click on the frequency field

This will invoke a drop down menu In the free text field type a period and enter a free text frequency (ie: .Q4H) Change Status If an intervention is added in error, you may change the status to remove or suppress the intervention from view Click in the status/due column and select to delete or complete the intervention

Change View The worklist displays active and discharge status items (only) by default To bring inactive entries to view click Change View Change View This routine provides the ability to update the worklist display In this case, inactive interventions are selected to be added to the display. Click Ok

Change View Worklist Display Note the Inactive Intervention now appears This intervention can be brought back to active status by selecting to edit the frequency Adding a New Intervention Most Interventions are added to the worklist through the plan of care Additional Interventions may be added as needed To add new interventions use the [Add] button

Add Intervention Routine The Quickest Method of searching for an Intervention is by [Any Word] Searches the entire intervention name Click [Any Word] and type the intervention name you wish to add Add Intervention Routine Type the name of the intervention and click enter

Select the Intervention from the List and click save Exercise L: Adding a New Intervention Patients primary language is Spanish and she prefers to discuss health related issues in this language. You will need to utilize the Telephonic/Video Interpretation device to communicate with your patient and her family. Add the telephonic/video interpretation device intervention. From the Intervention worklist, click [Add] Type Interpret and hit [Enter] Notice the intervention does not appear

Click [Any word] Notice the Telephonic/Video Interpretation Assessment appears Click the Intervention to select Click [Save] Confirm the Telephonic/Video Interpretation Assessment has been added to the worklist Write Note You may choose to document a free text note Or, select Text to enter a canned text (pre populated note)

Canned Text Upon selecting canned text, a list of available notes display Once the canned text is selected, the pre populated information will display within the write note screen. Canned text may be edited before saving. Exercise V: Notes Routine

Select Write Note Select Note Category: Nurse Select the Text Button

From the list of Canned Text, Downtime Note Click F4 to navigate through and enter each of the free text fields Click Ok Click Refresh EMR Notice the Notes Button Turns Red Click to view the note within the EMR Patient Care Reports Group of Meditech standard reports Available directly from PCS Status Board

You may print Patient Care Reports for an individual patient or a entire patient location Examples: Nursing Kardex Care Summary Report Active Orders Report Patient Care Reports Click Patient Reports Place a checkmark next to the patients name that you wish to print the report

Print for a location Navigate to find patient by outpatient location Clicking in the checkmark header to select all patients Reports Routine From the Patient Report Format Prompt, perform a look up to invoke the list of available reports Patient Reports List

You will be provided with a list of reports to choose from Select the report you wish to print Patient Reports Click ok to print the report Exercise: Patient Reports From the status board click the patient notes routine, click the reports button Place a checkmark to the left of your patients name

Click Reports Select the Drop down arrow Locate and Select the Vital Signs-Last 3 Days Click Ok And, select preview from the print/preview screen PAT Workflow Process

PCS Status Board Lists Find Patient by Outpatient Location: Day Surgery Reg SDC account Open Chart Go to the Summary panel Enter Allergies Enter Home Medication list Enter Last Taken Information

Click on Worklist Click on Add in the footer Click on Standards of Care at the top of the screen Choose PAT/Amb Day Surgery set Save On the Worklist check off the following assessments: Height and Weight Assessment Past Medical History Patient Rights for Care Decisions Pre-Adm Testing (PAT) Admission Info Vital Signs

SDC Workflow Process Click on Worklist and document the following assessments: Ambulatory/Day Surgery Adm Information assessment Pre-Surgical Documentation Reviewed IV/Invasive Line assessment to document the IV insertion I&O Intake and Output assessment Vital Signs

PACU Workflow Process From PCS Status Board: PCS Status Board

Lists Find Patient by Outpatient Location: Day Surgery SDC account or Inpatient account if patient was already an inpatient before going to surgery Open patient chart Click on Worklist and document on: PACU Holding Area-Inpt/ED Preop Note: for holding patients pre-op PACU Record IV /Invasive Line assessment I&O Intake and Output assessment

Vital Signs Any other assessment needed for patient If a patient comes to the PACU holding area from the ED or from the inpatient units: Document the following assessment: PACU Holding Area-Inpt/ED Preop Note: for holding patients pre-op For Outpatients going home from either PACU or SDC Document the following assessment: Phase II/Outpt Post Procedure Recovery

assessment

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