PROBLEM LIST: (AKA Interdisciplinary Care Plan)

Problem List needs to be addressed at least once a shift and should be initiated the first time you open a flowchart on a patient. Medact needs to be addressed at least once a shift. The LVN, RN, RT, PT, and RD can associate the nursing orders to the problems.

1. First, a problem needs to be identified before a nursing order or intervention can be associated. Open a flowchart.

2. To create a Problem List. Click on New Problem if there is no problem identified yet.

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Click on New Problem if there is no problem identified yet.

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In this example the category we have selected is Cardiovasc/Resp, the order description (PROBLEM identified) would be Impaired Gas Exchange.

A Category needs to be selected then select an order description.

• Most of the Problems listed on the system already have a predefined goal.

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In here, you can add, delete or edit.Select OK to continue.

Click on this icon to open MEDACT

This is where you would customize your entry to your needs. When done select OK.

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If there are no interventions created for this problem yet. Click on NEW.

In here, you need to select your category again and then your order descriptions ( INTERVENTIONS).

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Notice how our count is 3 at the top of your screen. With each additional nursing order that is added the count will increase.

Each nursing order entered will appear as below. Notice how we were able to add our own words to this frame. This is where you would customize your entry to your needs. When done select OK.

After selecting the category, then you need to select the order descriptions (INTERVENTIONS). You may add as many as you would like. When done with your selection select OK.

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Check the “Associate Problem” box and then highlight/ select the problem you are associating it with. Then click OK.

Your order will be added in the MedAct and at the same time you have associated this with the problem. Notice how the color is in blue. Blue: New active orders that haven’t been documented onBlack: Active orders that have been documented on

• Exit out from the Medact and return to your flowchart.

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Your order will be added in the MedAct and at the same time you have associated this with the problem.

Blue: New active orders that haven’t been documented onBlack: Active orders that have been documented on

Click on the Problem, select Intervention and make your commentUpdateWhen you click update, any nursing orders that have been associated to this problem will pop up in a boxIf you performed one of them at this time, check one/all of the interventions you just performedA ‘medact intervention” box will pop up for you to mark performedUpdate

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After updating your interventions, it will now confirm that you have performed each intervention that you have chosen. Just click Update. You can also put any comment you want that pertains to that intervention.

NOTE: If you document on a Problem in a Flowchart, and leave PROBLEM MODE on, you can jump to Chart Menu and go the Pharmacy and give a medication which will then attach to that Problem as part of your care plan.

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After you are done addressing the Problem:Close out of Problem Mode by clicking on it.

If your intervention is a medication, stay in problem modeSelect Chart Menu at the bottom-middle of the screenGo to PharmacyGive the medication via Med-VerifyUpdateExit from Pharmacy back to the FlowchartClose out of Problem Mode

Note: See Problem Activity Report under Reports Tab on the Virtual Chart for the documentation of the Care Plan. Answer Yes to include stricken/ amended data. Click Add All and Process. Then click on Print Problem Activity to start at beginning of stay. This will show your care plan in adobe format. See Below.

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Blue: New active orders that haven’t been documented onBlack: Active orders that have been documented on

To see a Problem Activity Report (Interdisciplinary Care Plan):

Follow the following pathway. Click on the Problem Activity Report under Reports on Patient’s Virtual ChartClick on Yes to include Stricken /amended data.Click on Add All Click Process Then click on Print Problem Activity to start at beginning of stay. This will show your care plan in adobe format. See Below.

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Under Reports Tab:Click on Problem Activity Report

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Click on Yes to include Stricken /amended data.

Click on Add All

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Click Process.

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