computerized physician documentation emergency department september 2012

Computerized PhysicianDocumentation

Emergency DepartmentSeptember 2012

Objective

• To enter patient documentation – Meditech (hospital, office, and home)

– Citrix (office and home use)

From the Tracker Board

• Step 1: Highlight the patient you want to document on• Step 2: Click on DOCUMENT on right side of screen

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If Previous Documentation

This screen appears once you click on Document, showing all Physician

documentation on this patient

Click on Enter New for new documentation

List of Documentation

If you care to continueDocumentation alreadystarted, click on the line you are continuing.

You will be taken to thereport.

Then click Edit/Amend.(red circle)

Mine vs. All

The Mine buttonallows you to viewonly those reportsdocumented by you.

ALL will allow you to see all reportson this patient.

Click Mine to see only yours.

Next Screen After ENTER NEWChoose the desiredTemplate and double click

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Initial Screen

Once template clickedBlue Highlight bar appears

General Adult SECTION LABELSHPI History of Present Illness

ROS Review of Systems

PEPhysical Exam

MDM Medical Decision Making

Depart Discharge

Can only view one section at a time.

Documenting

Nursing Documentation will default in if RN has completed assessments(ex: reports CHF, reports MI…)

DocumentClick on item desiredDrop Down Box may appear

Area shaded in darker blue relates to block on right

Use Search Box to start typing.List will shorten based on letters typed

Some fields will allow more than one check, others only one.

Click OK/Next to go to nextcomponent (line or query)

How to Document

– Once this information is complete, select OK/Next.• Will loop you to next item to document• May also go directly to another section by clicking on it• Some components have multiple choice selections• Choose by clicking on desired responses• To use all responses, document abnormal first, then click normal at top • Any item with a * next to it is a required field

How to Document– Continue with OK/Next to go on to next screen until all

screens are completed– For dates, T = today; T-1 = yesterday, etc.– For times, N = Now (current time on computer)

• Times are in military time– 8:00 am = 0800– 8:00 pm = 2000

– Any comments may be made in the open area at the bottom of the screen.

– To FILE:• Click on Submit• You will be asked for your fingerprint

Section Buttons

OK/Next: Inputs user’sInformation and goes tonext component, the onebelow it

OK: inputs information,does not go to the nextcomponent

Cancel: cancels any new information just putinto the component

Plus and Minus Signs

• A plus sign shows that there is more detail if you click and open

• A minus sign compresses the topic – can always be opened again by clicking

Options

If click bubble at bottom,can free text

When click OK, will populate field

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Comment FieldComment: Refers to spacehighlighted in darker blue on left.When documented,appears as a bubble.

Last bubble aboveComment allows free text and adds in actual space

CommentsClick button next to blank And field will appear to fill in

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Normal Button1. Click on Normal

2. Click OK3. Predetermined values

will automatically populatethe fields

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System Normals

To get system normals, double click header.(HPI, ROS, PE, etc)

This screen will appear.It allows you to default

normals for the systemsnot affected at this visit

into your documentation.

Click Preview before using to see normals

Typing Free Text

An open box (free text)allows for charts (such as these VS) to be brought into the chart

An open box alsoallows you to freetext items.

Navigate between the Stop Codes to add pertinent information. [ ]

V.S. fromNursing

Documentation

Next Stop (F2)

Next Stop takes youto the next set ofStop codes [ ] to allow you to move through a canned text

Functions of Free Text ScreenData Formats allows you to enter information from clinical reviewText provides canned text Next Stop (F2) takes you in the free text space to the next field to fill inOK/Next keeps current data and goes automatically to the next queryOK keeps data in fieldCancel leaves field and takes data outAdd Section provides detailed templates for more information Normal allows choice of inputting normal valuesQuick Save saves and allows you to resume next time you enter patientSubmit files as permanent part of chart. CANNOT EDIT afterwards

Free Text Buttons

Buttons worksimilarly to Word.

Free Text Buttonslisted above

Scroll Bars

Please look forscroll bars that denote there ismore to the screenthan is appearing

Hints to ChartingClick on any outliers first individually.

Then click on top of column that Is left and the rest will default in

Example:Clicked individually on: Oriented x3 Facial droop Speech slurredThen clicked on N at topfor N – all bubbles leftcompleted with “N”

Add a Section

To add more detail based on chief complaint,Click on Add Section and a list similar to theone above will appear

Data Formats / Text

To add labs, etc. (1) click on Data Formats (2) then click on appropriate component (3) allows data to be pulled in from elsewhere

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Quick Save

Quick Save buttonallows you to save

your data and comeback later to finish

without viewing what you have charted.

It does not completeyour documentation.

To file as part of record, use Submit.

Charting after Quick Save

When returningafter a Quick Save,use Resume button.

You will return to the original document.

To Sign

• Attendings to sign:– Click Draft or Quick Save to come back later– Click Submit and then Signed to complete

• Will be able to add addendum only• Will not be able to edit once signed

• Residents/Medical Students to sign:– Click Submit – Choose a Co-Signer– Choose Draft

To File Documentation• Pending

– Similar to Draft• Draft

– Used by Residents– Can also be used to Save

• Signed– Used by ED attending to finalize

• Cancelled– Needs reason – reason is free text

• Co-Signer – Is required for all Res/MS – Choose attending provider name for this

patient• Required Data

– Unable to sign before required fields completed

– Takes you directly to only those components

• Return– Takes you back to chart from where you left

off

Required Fields

Signed will not be highlighted until all required fields are completed.

Once Required Fields are complete, will be low-lit and Signed will be Highlighted.

Cancelled - Needs Reason

Reason

Notes

• If you would like to look at how the documentation will appear in report form, press F12 on keyboard

• Any item with a * is a Required Field• If Sign is not lit, there are Required Fields that

need to be completed– Choose Required Fields to finish needed items

To Complete after Patient Discharged• From Physician Desktop choose PATIENT ROUTINES • Choose Physician Documentation near bottom of list • Type in patient’s name to choose correct patient

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To Sign Documentation

Then use your fingerprint to sign documentation

Documentation is Complete!

ESigned is Status needed

to have documentcomplete.

Other Statuses: Temp Draft Pending Cancelled

Don’t Forget to Sign !

From the Tracker Board if Sign is Highlighted

ALL Orders/Documentation Have Been Signed by You

Sign Button is Low-Lit

For Questions The HELP Desk is available 24/7

Reach them at . . .216-241-5115

- or - 15115 (in the hospital)

Resources:Cathy Rhoades, Nursing IT Analyst

cathy.rhoades@csauh.com

Diane McGregor, RN – Training & Support Facilitatordiane.mcgregor@csauh.com