computerized physician documentation emergency department september 2012
TRANSCRIPT
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
Diane McGregor, RN – Training & Support [email protected]